APPLICATION FOR EMPLOYMENT

City of Washington 405 Jeffaraon Street

Washington, MO 63090 Attn: Human Resources

We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizenship status, genetic information or any other legally protected status.

(PLEASE PRINT) Position(s) Applied For Date of Application

How Did You Learn About Us?

D Advertisement D Relative D Inquiry D Employment Agency D Friend D Other

Last Name First Name Middle Name

Address Number Street City State Zip Code

Telephone Number(s) E-mail Social Security Number (Voluntary)

I I Best time to contact you at home is:

AM ----PM

If you are under 18 years of age, can you provide required proof of your eligibility to work? D Yes D No

Have you ever filed an application with us before? ·--- --·-- --- .. --- .. ......... ............ ..... ·---- ·---- ...... D Yes D No

-..... .... ........... ·· ···· ·- · ·--- · ·-- ................... ··--- · ·---·· ·--- , ............... If Yes, give date ______ _

Have you ever been employed with us before?.- ....................... ___ ··--- ·· -----, .. , ....... ..... ... .. .. ..... . D Yes

If Yes, give date ____ __ _

Do any of your friends or relatives, other than spouse, work here? ..... . ·--· ·--- ----- -.. -- ... -....... D Yes

Are you currently employed? ·- ·· --- .... ... ... ........... .... ___ ·· --- -··-·-·· ... .............. ... ... .. .. .. ,,, --- --- ·--- ....... D Yes

May we contact your present employer? .. .... ......... ,----- ·· ----..... -... ........ ... ....... .... ,, .. ____ , ___ . ______ , D Yes

Are you lawfully authorized to work in the United States? --- .......... ........ .. .......... _., .. _ .. , ______ , D Yes

Date available for work __ / __ / __ What is your desired salary range? ____ _

Are you available to work: (please indicate 1 2 3 shift)

D No

o No

D No

D No

D No

D Full-Time

D Part-Time

D Temporary

(please indicate Mornings Afternoon Evenings)

(please indicate dates available _ /_/_ - _ /_ /_ )

Are you currently on "lay-off" status and subject to recall? .... .. .... ·- --·. ·- --....... ..................... D Yes

Can you travel if a job requires it? ........ ... ..... .. ··- --, .............................. ··--·- · ·-- ··- ------- -...... -...... D Yes

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

D No

D No

'

EDUCATION

- - - --

Describe am specialized training, apprenticeship, skills and extra-curric:ular~cti\·ities.

Describe any job-related training recei\ ed in the United States military. _

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

1. Employer Dates Employed !From /To

Address Work Performed --------- -

Telephone Number(s)

Job Title I Supervisor

Reason for Leaving

2. Employer Dates Employed jFrom jTo

Address Work Performed

Telephone Number(s)

Job Title I Supervisor

Reason for Leaving

3. Employer Dates Employed jFrom jTo

Address Work Performed

Telephone Number(s)

Job Title I Supervisor

Reason for Leaving

4. Employer Dates Employed jFrom jTo

Address Work Performed ·-

Telephone Number(s)

Job Title I Supervisor

Reason for Leaving

If you need additional space, please continue on a separate sheet of paper.

List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other

protected status:

I

I,

ADDITIONAL INFORMATION

Other Qualifications

Summarize special job-related skills and qualifications acquire l from employment or other experience.

SPECIALIZED SKILLS

_ Terminal

_ PC/MAC

_Typewriter

WPM

( CHECK SKILLS/EQUIPMENT OPERA TED)

_Spreadsheet

_Word Processing

_ Shorthand

WPM

Production/Mobile Machinery (list) Other (list)

- -

State auy additional i11formatio11 you feel may be l,elpJitl to us in considering your application.

-- - -

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation? __ YES __ NO

REFERENCES

l. _____ _ _____ ___ _ _______ ( __ ) ---------- -(Name) Phone#

(Address)

2. _____ __ ________________ ( __ ) ---------- -(Name) Phone#

(Address)

3. _ _ _ __________ _ _ __ ( _ _ ) --- --- --(Name) Phone#

(Address)

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant Date

FOR PERSONNEL DEPARTMENT USE ONLY ------ - - --

Arrange Interview O Yes O No

Remarks -------- -----------------

INTERVIEWER DATE

Employed D Yes D No Date of Employment ____________ _

Hourly Rate/ Job Title _ _______ Salary _ __ _ Department _____ _ _ ___ _

By _______ _ _ __________________ _ NAME AND TITLE DATE

This Application For Employment is sold for general use throughout the United States. Amsterdam Printing assumes no responsibility for the use of said form or any questions which, when asked by the employer of the job applicant, may violate State and/or Federal Law.

Rev 10/19 Re-order Form #23960 (23962 imprinted) ©copyright 2020 Amsterdam Printing, Amsterdam, N.Y. 12010 Toll Free 1-866-466-1438 or online www.amsterdamforms.com /'.msterdam ·

-

' FOR PERSONNEL DEPARTMENT USE ONLY

Position(s) Applied For Is Open: Cl Yes CJ No

Position(s) Considered For:

Date _______ ___ _

--

CERTIFICATE OF APPLICANT

AUTHORIZATION FOR RELEASE OF INFORMATION

(READ CAREFULLY BEFORE SIGNING)

I, (Print Full Name) _____________________________hereby certify that all statements made on or in

connection with this application are true and complete to the best of my knowledge and belief. I understand

and agree that any mis-statements or omission of material facts will cause forfeiture on my part of all rights to

employment with the City of Washington, Missouri.

I hereby authorize all law enforcement agencies, the Veteran Administration, U.S. Army, U.S. Air Force, all

military agencies, tax bureaus, credit bureaus, schools and universities, to furnish the holder of this release

with all and any available information regarding me in order that he may determine my suitability for

employment.

I authorize the holder of this release to make inquiry of my present and past employers regarding my

character, integrity, and reputation.

I authorize the release of any and all information regarding my employment, credit or any other information,

where personal or otherwise, that may or may not be in their records, and release said company of person

from all liability for any damage whatsoever that my issue from furnishing such information to the holder of

this release.

A copy of this authorization will be considered as effective and valid as the original.

I give consent to contact me via email at:

Email address ______________________________________________

Are you related to any City of Washington employee or elected official? ☐Yes ☐ No

If yes, state who and how are you related? __________________________________________________

_________________________________________ __________________________

Signature of Applicant Date

DRIVER QUALIFICATIONS

Inspection of License Information Circle Those That Apply

A. Driver’s License Classification: A B C E F H M

B. Endorsements: B C H M N P T

C. Restriction Code A G C D F I J L O U W Z

D. License Number: ___________________________________

E. Expiration Date: ___________________________________

F. Address: ___________________________________

Number & Street

City State Zip Code

If there are any changes to the driver’s classification, expiration date or restriction code, which

may impact the driver’s ability to meet City driving requirements, the driver must notify

Human Resources immediately and will not be allowed to operate City vehicles until resolved.

All moving violations must be disclosed and attached to this document.

Type of Vehicle(s) Driver is qualified to operate _____________________________________

____________________________________________________________________________

Printed Name: _____________________________________________

Signature: __________________________________________________

Drug Screening and Criminal Record Check Consent Form

Dear Applicant:

The City of Washington has adopted a Drug Screening and Criminal Record Check

Process for all new hires.

All Applicants with the City of Washington must sign below AND, if under the age of 18

years, have a Parent/Guardian sign this form for parental consent for the drug screening and

criminal record check.

Only the applicants offered the positions will be required to submit to a drug screening

and criminal record check.

The position will be contingent upon receiving a negative result from the drug screening

and criminal record check. This consent also allows the release of the test results to an

authorized city representative for review.

_________________________________________

Job Applicant Signature Date

__________________________________________

Parent/Guardian Signature Date

*FORM MUST BE RETURNED WITH YOUR APPLICATION*

REQUEST FOR CRIMINAL RECORD CHECK

GENERAL INFORMATIONAPPLICANT’S LAST NAME FIRST MIDDLE JR/SR

MAIDEN / ALIAS LAST NAME FIRST MIDDLE JR/SR

ADDRESS STREET – P.O. BOX CITY STATE ZIP CODE

SEX MALE FEMALE

DATE OF BIRTH(MM/DD/YYYY)

SOCIAL SECURITY NUMBER RACE BLACK INDIAN OTHER WHITE ASIAN

This Organization Participates in E-Verify

This employer participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S. If E-Verify cannot confirm that you are authorized to work, this employer is required to give you written instructions and an opportunity to contact Department of Homeland Security (DHS) or Social Security Administration (SSA) so you can begin to resolve the issue before the employer can take any action against you, including terminating your employment. Employers can only use E-Verify once you have accepted a job offer and completed the Form I-9.

E-Verify Works for Everyone

For more information on E-Verify, or if you believe that your employer has violated its E-Verify responsibilities,

please contact DHS.

Esta Organización Participa en E-Verify

Este empleador participa en E-Verify y proporcionará al gobierno federal la información de su Formulario I-9 para confirmar que usted está autorizado para trabajar en los EE.UU.. Si E-Verify no puede confirmar que usted está autorizado para trabajar, este empleador está requerido a darle instrucciones por escrito y una oportunidad de contactar al Departamento de Seguridad Nacional (DHS) o a la Administración del Seguro Social (SSA) para que pueda empezar a resolver el problema antes de que el empleador pueda tomar cualquier acción en su contra, incluyendo la terminación de su empleo. Los empleadores sólo pueden utilizar E-Verify una vez que usted haya aceptado una oferta de trabajo y completado el Formulario I-9.

E-Verify Funciona Para Todos

Para más información sobre E-Verify, o si usted cree que su empleador ha violado sus responsabilidades de E-Verify, por

favor contacte a DHS.

888-897-7781

dhs.gov/e-verify

English / Spanish Poster

City of Washington Job Description

Library Clerk

Status: Part-Time

FLSA Status: Non-exempt

Department: Library

Immediate Supervisor: Library Director

General Purpose of Position

Responsible for various types of clerical work centering on circulation and service desk.

Major Duties and Responsibilities (Essential Functions)

Operates circulation desk

Greets patrons as they enter the library

Checks in and checks out books, DVDs, and other library materials

Collects fines, book sale, fax, and copy monies

Accepts material requests

Assists patrons in placing material holds, using library OPAC, and their “My Account”

Provides customer service to patrons

Answers phone in a courteous manner

Responds to questions by patrons

Conducts research to answer patron reference questions

Assists patrons in locating library materials, internet, and computer questions

Marginal Duties and Responsibilities

Performs other duties as assigned

Job Context

Working Conditions

The work environment characteristics described here are representative of those an employee encounters while

performing the essential functions of this position. Reasonable accommodations may be made to enable individuals

with disabilities to perform the essential functions.

While performing the duties of this position, the employee is not regularly exposed to adverse conditions. The noise

level in the work environment is usually moderate.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully

perform the essential functions of this position. Reasonable accommodations may be made to enable individuals

with disabilities to perform the essential functions.

While performing the duties of this position, the employee is regularly required to sit; use hands to finger, handle,

hold or grip, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand,

walk, bend, climb or balance and stoop, kneel, crouch, or crawl. Lifting, moving, pushing or pulling up to 10 pounds

does occur when shelving books and materials. Specific vision abilities required by this job include close vision,

color vision, depth perception and ability to adjust focus.

Required Education and Experience

High school diploma or its equivalent. Experience in a library, working with computers and customers.

Preferred Education and Experience

Two to three years related experience and/or training; or a associates degree from a college or university; or

equivalent combination of education and experience.

Licenses and Certification

Knowledge, Skills and Abilities

Knowledge

Knowledge of library practices and procedures, software systems, reference books and materials, MAR records,

American Library Association guidelines and practices

Knowledge of Dewey decimal system and cataloging techniques

Knowledge of proper grammar and use of English in speaking and writing

Knowledge of Spanish not necessary, but useful

Knowledge of computer operations and applications, including work processing and spreadsheets

Knowledge of principles and processes for providing customer and personal services. This includes identifying

customer needs, meeting standards for service and customer satisfaction

Skills and Abilities Effective communication skills orally and in writing

Ability to write routine reports and correspondence

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and

procedure manuals

Ability to apply concepts of basic algebra and geometry

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram

form

Ability to deal with problems involving several concrete variables in standardized situations

Ability to prioritize daily work flow

Ability to meet specified or required deadlines

Ability to maintain accurate records

Ability to attend to duties reliably and predictably

Ability to follow departmental and City policies and procedures

Ability to alphabetize

Ability to use various pieces of office equipment including: typewriter, copier and Fax Machine

Ability to maintain confidentiality

Ability to use various office software, including work processing and spreadsheets

Ability to establish and maintain effective working relationships with a wide range of people, public and fellow

staff

Supervision

n/a

Signature and Approval

________________________________ __________________

Employee Date

________________________________ __________________

Department Director Date

________________________________ __________________

Human Resources Date

________________________________ __________________

City Administration Date

The above statements are intended to describe the general nature and level of work being performed by individuals

assigned to this job. They are not intended to be an exhaustive list of all essential functions, marginal functions,

responsibilities, duties, and skills required of personnel so classified in this position.