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2. Exact Title Of Position You Are Applying For*
4. 1. PERSONAL DATA
6. Name (Last, First, Middle)*
7. Home Telephone*
9. Mailing Address (Number and Street)*
10. Work Telephone
12. (City, State, Zip)*
13. Date of Birth *
15. Do you have a valid Driver's License?*

    1. Yes

    1. No
17. State:
18. Number:
19. Class:
20. Expiration Date:
22. Social Security Number (Optional)
24. 2. PHYSICAL CONDITIONS OR LIMITATIONS
26. Do you have any physical condition or limitations that would prevent you from performing all the duties of this position on a regular and continuing basis?

    1. Yes

    1. No
28. 3. PREVIOUS CITY EMPLOYMENT AND CURRENT EMPLOYMENT OF A RELATIVE
30. A. Have you been previously employed by the City of West Columbia?

    1. Yes

    1. No
32. B. Are you currently participating in the Public Employees Retirement System?

    1. Yes

    1. No
34. C. Have you ever participated in the Public Employee's Retirement System?

    1. Yes

    1. No
36. D. List any relatives currently employed by the City of West Columbia and their relationship to you:
38. 4. EDUCATION AND TRAINING
40. Choose Highest Grade Completed
    -- Select One --123456789101112
42. Name & Location Of High School
44. Are You A High School Grad?

    1. Yes

    1. No
45. Have You Passed the GED?

    1. Yes

    1. No
47. Schools Attended Other Than High School
48. Course Of Study
50. Credits Earned
51. Degree Or Certificate Rec'd
53. Please describe additional course work or training (including military) which would qualify you for this position:
55. Please list certificates or licenses of professional or vocational competence you possess which relate to this position:
57. Please list languages other than English which you speak read or write:
59. Special Skills:

    1. Typing
    2. Computer Hardware
    3. Computer Software
61. 5. WORK EXPERIENCE
    You should respond completely to the information requested n this section and attempt to cover all the requirements listed in the job announcements. LIST YOUR MOST RECENT EMPLOYMENT FIRST. Describe different positions held with the same employer in different blocks, showing dates, etc. List all experiences, paid and voluntary, related to the position for which you are applying. Additional sheets should be attached to this application when necessary to fully describe related experience, training and education. DO NOT ENTER "SEE RESUME"
63. A.
65. From (MO. & YR.)
66. Title of your present or most recent position
68. To (MO. & YR.)
69. Number, Street, City, State
71. Total Time
72. Employer's Business
73. Salary, Per
75. Duties Performed
77. Name of Supervisor
78. Reason For Leaving
80. B.
82. From (MO. & YR.)
83. Title of your present or most recent position
85. To (MO. & YR.)
86. Number, Street, City, State
88. Total Time
89. Employer's Business
90. Salary, Per
92. Duties Performed
94. Name of Supervisor
95. Reason for Leaving
97. C.
99. From (MO. & YR.)
100. Title of your present or most recent position
102. To (MO. & YR.)
103. Number, Street, City, State
105. Total Time
106. Employer's Business
107. Salary, Per
109. Duties Performed
111. Name of Supervisor
112. Reason for Leaving
114. D.
116. From (MO. & YR.)
117. Title of your present or most recent position
119. To (MO. & YR.)
120. Number, Street, City, State
122. Total Time
123. Employer's Business
124. Salary, Per
126. Duties Performed
128. Name of Supervisor
129. Reason for Leaving
131. E.
133. From (MO. & YR.)
134. Title of your present or most recent position
136. To (MO. & YR.)
137. Number, Street, City, State
139. Total Time
140. Employer's Business
141. Salary, Per
143. Duties Performed
145. Name of Supervisor
146. Reason for Leaving
148. 6. EXPLANATION OF PREVIOUS ITEMS
     Use this space to provide additional information as required by this application. Attach additional sheets if necessary.
150. 7. CONVICTION RECORD (REQUIRED FROM ALL APPLICANTS)
     Answer this section truthfully, including both minor and serious offenses of which you were convicted. ANY OMISSIONS ARE GROUNDS FOR REJECTION OF THE APPLICATION, REMOVAL OF NAME FROM THE ELIGIBILITY LIST OR DISMISSAL FROM POSITIION.
152. Have you ever been convicted as an adult for any violation of the law? Exclude traffic violations under $200 and convictions more than two years old for violation of Health and Safety Code 11357(b), 11360(b), 11364, 11365 and 11550 as related to marijuana. You may also exclude any convictions whuch resulted in a referral to and participation in any diversion program. Conviction is not necessarily a bar to employment. Each case will be given individual consideration. Failure to list all convictions other than those excluded above may disqualify you from further consideration.

     1. Yes

     1. No

     If yes, provide the information requested below for each conviction. Be specific, give name of the offense, not simply misdemeanor or felony. DO NOT LIST ARRESTS - ONLY CONVICTIONS.
154. OFFENSE
155. OFFENSE
156. OFFENSE
158. DATE
159. DATE
160. DATE
162. PLACE
163. PLACE
164. PLACE
166. SENTENCE/FINE
167. SENTENCE/FINE
168. SENTENCE/FINE
170. 8. CERTIFICATE OF APPLICANT - PLEASE READ CAREFULLY
172. I certify that the foregoing information and answers are true, complete and correct. I understand that any misrepresentation or omission of materials facts is cause for rejection of application, removal from the eligibility list, suspension or dismissal. I hereby authorize the City of West Columbia to investigate all statements contained on this application form. *
174. IF APPOINTED TO A CITY JOB, APPLICANTS WILL BE REQUIRED TO SUBMIT PROOF OF IDENTITY AND ELIGIBILITY TO WORK IN THE UNITED STATES. PRIOR TO HIRING, A CANDIDATE WILL BE REQUIRED TO BE DRUG-TESTED AT CITY EXPENSE. FOR SOME POSITIONS, A FULL MEDICAL AND PSYCHOLOGICAL EVALUATION AND DETAILED BACKGROUND INVESTIGATION WILL BE REQUIRED. CONVICTION RECORDS WILL BE CHECKED.
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176. 1. Receive an email copy of this form.
177. Email address

     This field is not part of the form submission.

178. Submit

* indicates a required field