Grants Administrator

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

The City of Texarkana, Arkansas does not discriminate on the basis of race, color, religion, sex, national origin, age, marital or veteran status, political affiliation, handicapped status, or any other legally protected status. Print or type answers to each question clearly and completely. All questions must be answered. This is an application for employment and no employment contract is being offered. The City of Texarkana may change wages, benefits, and conditions of employment at any time. If you need assistance in completing this application for or in participating in the selection process, please speak with Personnel.

Position Desired:*

Date of application*

Date available for work*

(If part time, what hours and days)

First Name*

Last Name*

Address*

City*

State / Province*

ZIP / Postal Code*

Country*

Home Phone*

Business Phone*

If you are under 18 years of age, can you provide proof of your eligibility to work?

Yes

Have you ever worked for this City?

Yes

If yes, give prior name, dates and reason for leaving

Are you legally eligible to work in the United States?

Yes

If yes, give prior name, dates and reason for leaving

List all licenses you hold: (Drivers, electricians, etc.)

Type

Number

Exp. Date

Type

Number

Exp. Date

Are you related to any city employee or any member of the City Board of Directors?

Yes

If so, give name, department, and relationship

Have you ever been convicted of a felony in the last 7 years or are you currently charged with the commission of a felony?

Yes

If yes, state what, when, and how: (Note: This information does not in itself disqualify you for employment.)

Military Service

Branch

Date of Entry

Indicate specific military experience or training that is job related

In accordance with the American with Disabilities Act, the City of Texarkana will make reasonable accommodationfor individuals qualified to perform all essential aspects of the job function. After reviewing the essential job functions from the attached job description, are you able to do them?

Yes

If no explain

Educational Record

Elementary

Name and Address of School

Course of Study

Check Last Year Completed

Did you graduate

Yes

List Diploma or Degree

High

Name and Address of School

Course of Study

Check Last Year Completed

Did you graduate

Yes

List Diploma or Degree

College

Name and Address of School

Course of Study

Check Last Year Completed

Did you graduate

Yes

List Diploma or Degree

College

Name and Address of School

Course of Study

Check Last Year Completed

Did you graduate

Yes

List Diploma or Degree

EMPLOYMENT EXPERIENCE 1

Begin with current or later employment.

Employer Name

Employer Address

City

State / Province

ZIP / Postal Code

Country

Date Started

End Date

Phone

Job Title

Supervisor

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Work Performed

EMPLOYMENT EXPERIENCE 2

Begin with current or later employment.

Employer Name

Employer Address

City

State / Province

ZIP / Postal Code

Country

Date Started

End Date

Phone

Job Title

Supervisor

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Work Performed

EMPLOYMENT EXPERIENCE 3

Begin with current or later employment.

Employer Name

Employer Address

City

State / Province

ZIP / Postal Code

Country

Date Started

End Date

Phone

Job Title

Supervisor

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Work Performed

EMPLOYMENT EXPERIENCE 4

Begin with current or later employment.

Employer Name

Employer Address

City

State / Province

ZIP / Postal Code

Country

Date Started

End Date

Phone

Job Title

Supervisor

Hourly Rate/Salary Starting

Hourly Rate/Salary Final

Work Performed

Specify equipment or office machines you operate

Give name, address and telephone number of three references who are not related to you and are not previous employers.

Employer Name

Employer Address

City

State / Province

ZIP / Postal Code

Country

Phone

Employer Name

Employer Address

City

State / Province

ZIP / Postal Code

Country

Phone

Employer Name

Employer Address

City

State / Province

ZIP / Postal Code

Country

Phone

Employer Name

Employer Address

City

State / Province

ZIP / Postal Code

Country

Phone

Iunderstand that this application is not intended to create any contractual or other legal rights. It does not alter the at-will employment status nor does it create an employment contract for any specific period of time.I certify that I have made no willful misrepresentations in this application nor have I withheld information in my statements and answers to questions. I am aware that the information given by me in my application will be investigated, with my full permission, and that any misrepresentations may cause my application to be rejected or my employment terminated.I authorize any former employer to release to the City or its authorized representation any and all employment records and other information it may have about my employment. I understand that the information will be used for the purpose of evaluation my application for employment with the City. A photocopy of this authorization shall be as valid as the original. I understand that this application is the property of the City and will become a part of my file if I am accepted for employment.I understand that this application, once filed, may be subject to disclosure as a publicrecord under the Arkansas Freedom of Information Act.

Signature of Applicant

Date

APPLICANT INFORMATION FOR RECORD KEEP REQUIREMENTS

The City of Texarkana, Arkansas is an Equal Opportunity Employer. We request that you voluntarily provide the following information which will be used to study recruitment and employment patterns and to proved, as requested, statistical data to certain federal compliance agencies. This information WILL NOT be used in the employment process;and failure to provide the information WILL NOT jeopardize your opportunity for employment with the City of Texarkana, Arkansas.

Position in which you have applied

Date of application

SEX AND RACE/ETHNIC IDENTIFICATION

Sex (check one)

Male

Female

RACE/ETHNIC

For the purpose of Equal Opportunity, race/ethnic categories are identified as follows: (Please check the category which identifies your race/ethnic background.)

NOTE: The information provided on this form will be kept separate from the employment application form.