Kersey, CO

Step One

An Equal Opportunity Employer
We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, genetic information or any other status protected by law or regulation. It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.
Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature on the back of the application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job related information.
Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature on the back of the application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job related information.
Job Applied for*
Today's Date*
Which type of employment are you seeking?*
When could you start work?*
Hours of work (per week) desired*
How did you hear about the position?*
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Personal Information

First Name*
Last Name*
Middle Name*
Address1*
Address2
City*
State*
Zip*
Phone Number*
Email Address*
If offered a position with the Town of Kersey, you will be required to furnish proof of your eligibility to work in the U.S.
I am (please check only one box)*
1. 16 years or older
1. 18 years or older
1. 21 years or older
Have you ever applied here before?*
If yes, when?
Have you been concivcted of any law violation?*
If yes, give details
(A conviction will not necessarily disqualify an applicant for employment.)
Have you had your driver's license suspended or revoked in the last 3 years?*
If yes, give details:
If employed, do you expect to be engaged in any additional business of employment outside of our job?*
If yes, give details
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Education

High School or GED*
Address*
Dipolma/Degree Certificate*
College or University*
Address*
Degree*
Vocational or Techinical*
Address*
Degree/Certificate*
Skills/Additional Training
What skills or additional training do you have that are related to the job for which you are applying?
Equipment
What machines or equipment can you operate that are related to the job for which you are applying?
List professional, trade, business or civic activities and offices held.
Exclude labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, genetic information or other protected status.
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Employment History

List names of employers in consecutive order with present or last employer listed first.
Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Note: A job offer may be contingent upon acceptable references from current and former employers.
Company
Address
City
State
Zip Code
Phone Number
Position
Supervisor
May we contact your previous supervisor for a reference?*
1. Yes
2. No
1. N/A
Responsibilities
Employed From - To (Date)
Salary
Reason for Leaving
Company
Address
City
State
Zip Code
Phone Number
Position
Supervisor
May we contact your previous supervisor for a reference?*
1. Yes
2. No
1. N/A
Responsibilities
Employed From - To (Date)
Salary
Reason for Leaving
Company
Address
City
State
Zip Code
Phone Number
Position
Supervisor
May we contact your previous supervisor for a reference?*
1. Yes
2. No
1. N/A
Responsibilities
Employed From - To (Date)
Salary
Reason for Leaving
Have you worked or attended school under any other names?*
If yes, give names
Are you presently employed?*
If yes, whom do you suggest we contact?
Have you been fired for a job or asked to resign?*
If yes, please explain
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References

Please list three professional references. No relatives or former employers
First Name*
Last Name*
Address*
City*
State*
Zip Code*
Phone Number*
Email Address
First Name*
Last Name*
Address*
City*
State*
Zip Code*
Phone Number*
Email Address
First Name*
Last Name*
Address*
City*
State*
Zip Code*
Phone Number*
Email Address*
Upload Your Resume*
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Law Enforcement Certification (Required for all Police Department Applicants)

POST Number
Issue Date
Academy Attended
Dates Attended
Address
City
State
Zip Code
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Disclaimer & Signature

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statement contained in this application. I also authorize, whether listed or not, any person, school, current employer, an organization to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug scree=ning examination. I hereby consent to a pre-and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned up my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to the work for which I am applying. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENT BY MANAGEMENT OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN A EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NO GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRES AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASONA DN WITH OR WITHOUT NOTICE.
I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statement contained in this application. I also authorize, whether listed or not, any person, school, current employer, an organization to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug scree=ning examination. I hereby consent to a pre-and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned up my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to the work for which I am applying. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENT BY MANAGEMENT OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN A EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NO GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRESIDENT OF THE ORGANIZATION HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE PRESIDENT AND THE EMPLOYEE. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRES AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASONA DN WITH OR WITHOUT NOTICE.
Applicant Signature*
Date*

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Town of Kersey Job Application

Steps

Step One

Personal Information

Education

Employment History

References

Law Enforcement Certification (Required for all Police Department Applicants)

Disclaimer & Signature

Town of Kersey

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