CITY OF STURGIS, SOUTH DAKOTA
EMPLOYMENT APPLICATION

You must answer all questions to be considered. The City does not discriminate based upon race, color, national origin, religion, sex, age, disability, sexual orientation or veteran’s status. EOE.

NOTE: Navigating away from this form will cause your work to be lost. To submit, click the button at the bottom of this page.

CONTACT INFORMATION:

First Name:*

Last Name:*

Present Address:*

City:*

State:*

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Zip Code:*

Telephone No.:*

Email Address:

Position Applying For:

Desired Shift(s)*

Full-time Part-time Temp / Seasonal

Rotating Shifts Weekends Nights

GENERAL EMPLOYMENT INFORMATION:

If hired, can you provide that you have the legal right to obtain employment in the USA? (Proof of eligibility will be required upon offer of employment.)*

Yes

No

Have you ever been employed by City of Sturgis?*

Yes

No

If yes, give dates and job titles.

If the position you are applying for requires driving, do you possess a current driver’s license?

Yes

No

If required, indicate your Driver's License Number, State, and Expiration Date:

If the position you are applying for requires driving, has your license ever been suspended, revoked, or put on probation?

Yes

No

If yes, explain.

Have you ever been convicted of a crime (other than minor traffic violation)? *

Yes

No

If yes, when, where and what was the disposition of the case?

(Conviction is not an automatic disqualification from employment.)

Do you have any other commitments to another employer which might affect your employment with City of Sturgis?*

Yes

No

If yes, explain.

If required for the position, are you willing to undergo a post-employment offer physical prior to reporting to work?*

Yes

No

(Note: Failure to pass physical may result in job offer being withdrawn.)

If required for the position, are you willing to undergo a pre-employment drug screen?*

Yes

No

(Acceptable forms of testing will be used. Failure to pass drug screen may result in job offer being withdrawn.)

Have you ever been suspended by an employer for either misconduct or poor job performance?*

Yes

No

If yes, explain.

Have you ever been discharged, asked to resign, or terminated for any reason other than layoff or lack of work?*

Yes

No

If yes, explain.

If hired, do you agree to follow all policies and procedures for the City of Sturgis? *

Yes

No

EDUCATION AND TRAINING

Elementary School:

Name and City/State of School

Check last year completed

5th 6th

7th 8th

High School:

Name and City/State of School

Course of Study:

Check last year completed

9th 10th

11th 12th

Did You Graduate?

Yes

No

Comments / Honors rec'd

College or University:

Name and City/State of School:

Course of Study:

Check Last Year Completed:

1 2

3 4

Did you graduate?

Yes

No

Comments / Honors rec'd

Graduate / Professional

Name and City/State of School:

Course of Study:

Check Last Year Completed:

1 2

3 4

Did you graduate?

Yes

No

Comments / Honors rec'd

Trade or Other Technical Training:

Name and City/State of School:

Course of Study:

Check Last Year Completed:

1 2

3 4

Did you graduate?

Yes

No

Comments / Honors rec'd

Special skills acquired from employment or other experiences:

Do you have any licenses, certificates, publications, or professional achievements that would support your application?

Yes

No

If yes, please list.

Do you belong to any professional societies or organizations?

Yes

No

If yes, please list.

(You may exclude those which indicate race, color, national origin, religion, age, sex, disability, or are not relevant for the position.)

REFERENCES

Given the name, occupation, address, and telephone number of references who are familiar with your qualifications and are not related to you.

Reference Number 1:

Reference Number 2:

Reference Number 3:

EMPLOYMENT HISTORY:

Begin with present or most recent employer and account for the last three positions you have held.

Employer Number 1:

Employer Name:

Type of Business:

Employer's Address:

Phone Number:

Dates of employment:

Starting Position:

Starting Rate:

Final Position:

Current / Ending Rate:

Name and Title of Immediate Supervisor:

Brief Description of Duties:

Number of employees that you supervised:

Reasons for seeking new employment:

May we contact this employer?

Yes

No

Employer Number 2:

Employer Name:

Type of Business:

Employer's Address:

Phone Number:

Dates of employment:

Starting Position:

Starting Rate:

Final Position:

Ending Rate:

Name and Title of Immediate Supervisor:

Brief Description of Duties:

Number of employees that you supervised:

Reasons for seeking new employment:

May we contact this employer?

Yes

No

Employer Number 3:

Employer Name:

Type of Business:

Employer's Address:

Phone Number:

Dates of employment:

Starting Position:

Starting Rate:

Final Position:

Ending Rate:

Name and Title of Immediate Supervisor:

Brief Description of Duties:

Number of employees that you supervised:

Reasons for seeking new employment:

May we contact this employer?

Yes

No

CERTIFICATION

IMPORTANT: READ CAREFULLY BEFORE SIGNING

I certify that the information in this application is true, correct, and complete, and I understand that any omissions, false or misleading
statements supplied in this application or during the interview process will result in dismissal. I authorize the City of Sturgis to verify the
information set forth in this application and to obtain additional information relating to my background, as permitted by law. I
authorize all persons, schools, companies, corporations, credit bureaus, and law enforcement agencies to supply any information
concerning my background and release the City of Sturgis, from all liability for any damages that may result from furnishing same to
the City.

Should I receive an offer of employment, I hereby consent to a physical examination before I begin work (if required for position). I also consent to pre-employment alcohol and/or drug testing (if required for position). I understand that my beginning work will be contingent upon acceptable job-related results of this medical examination and acceptable results of substance abuse testing. If employed, I promise, as a condition of employment, that I will submit to Human Resources verification of my U.S. Employment eligibility as required by INS Form I-9.

I understand that nothing in this application or in my acceptance of an offer of employment creates any contractual obligation upon me or upon the City to continue my employment in the future. I understand that my employment relationship with the City of Sturgis is “at will,” which means my employment may be terminated by either myself or the City of Sturgis at any time for any reason. No representative of the City has the authority to enter into an oral agreement with a prospective employee or employee during employment for any specified period of time or for any specific term or condition of employment or to make any agreement or representation which is contrary to the foregoing.

I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE ABOVE, INCLUDING THE “AT WILL” STATUS OF MY EMPLOYMENT.*

Yes

No

Electronic Signature (type your name):*

I will be submitting a resume, cover letter, or other documentation to supplement this application.

Resume Cover Letter

Certifications Other