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Applicant Information

Fill out this form completely. Additional employment information may be uploaded or sent to our offices to support the provided information.
Last Name*
First Name*
Email Address
If we should need to contact you in the future
Home Address*
City*
State*
Zip*
School Address
School City
State
Zip
Primary Phone*
Secondary Phone
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Position Information

Background Information

If you are under the age of 18, are you able to furnish a work permit?
1. Yes
1. No
Do you have the legal right to work in the United States?
1. Yes
1. No
Have you previously been employed by the City of Lima?
1. Yes
1. No
If yes, specify date(s):
If yes, specify date(s): Start Date
—
If yes, specify date(s): End Date
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Education

Employment History 1

Instructions
List all employments for the past 10 years, starting with the most recent position. All information MUST be completed. You may attach a resume, but not in place of completing the required information.
Employer Name
Employer Address
City
State
Zip
Supervisor Name
Supervisor Phone Number
Employed From
Employed From Start Date
—
Employed From End Date
Starting Salary
Ending Salary
Job Title
Reason for Leaving
Duties & Responsibilities
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Employment History 2

Employer Name
Employer Address
City
State
Zip
Supervisor Name
Supervisor Phone Number
Employed From
Employed From Start Date
—
Employed From End Date
Starting Salary
Ending Salary
Job Title
Reason for Leaving
Duties & Responsibilities
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Employment History 3

Employer Name
Employer Address
City
State
Zip
Supervisor Name
Supervisor Phone Number
Employed From
Employed From Start Date
—
Employed From End Date
Starting Salary
Ending Salary
Job Title
Reason for Leaving
Duties & Responsibilities
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For Clerical Applicants Only

Do you type?
1. Yes
1. No
If YES, words per minute:
Computer Skills (Hardware/Software)
Summarize specialized skills and qualifications acquired from employment or experience:
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CERTIFICATION AND AUTHORIZATION

The above information is true and correct. I understand that, in the event of my employment by the City of Lima, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.
I authorize the City of Lima to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the city of Lima and will hold the City of Lima and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information.
I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the City of Lima is intended to create an employment contract between myself and the City of Lima under which my employment could be terminated only for cause. On the contrary I understand and agree that, if hired, my employment will be terminable at will and may be terminated by the City of Lima or me at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form I-9.
I hereby acknowledge that I have read and agree to the above statements.
Electronic Signature*
By checking "I Agree" you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.
1. I Agree

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Applicant Information

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Employment History 1

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Employment History 3

For Clerical Applicants Only

CERTIFICATION AND AUTHORIZATION

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