TOWN OF WOOLWICH
EMPLOYMENT APPLICATION
Date: _____________
Name_________________________________________ Telephone No. _______________
Last First Mi.
Address _______________________________________ Soc. Sec. No. ________________
No. Street City State Zip
Position applied for ______________________
Do you have a car available for your own use? Yes No
Valid Drivers License? Yes No
Have you ever been convicted of a felony? Yes No (Conviction is not
necessarily a bar to employment) If yes, please explain:
Please indicate the highest level of education achieved: High School (GED)
Two Year College Four Year College
Describe specialized training or skills for this position: _____________________
Employment Background
- Employer ________________________ Supervisor’s Name __________________
Address ____________________ Job Title ____________ Phone ________
Dates employed: From _______ To _________
Reason for leaving_______________________
- Employer ____________________ Supervisor’s Name _________________
Address _____________________ Job Title ___________Phone ________
Dates employed: From ________ To __________
Reason for leaving_________________________
- Employer ___________________ Supervisor’s Name ________________
Address ____________________ Job Title ___________ Phone ________
Dates employed: From ________ To __________
Reason for leaving __________________________
The Town of Woolwich is an Equal Opportunity Employer.
Any falsification of information or misleading information on this application shall be fully sufficient grounds to refuse to employ or, having been employed, shall be immediate grounds for dismissal.
I hereby authorize the Town of Woolwich to make inquiry of and request information from any individuals, present or former employers, schools and colleges, motor vehicle bureaus, and any other entities that may possess information concerning me or that may be custodians of records relating to me, including Workers’ Compensation. I hereby release those sources from any liability for release of such information.
Applicant’s Signature ______________________ Date ______________