City of

VINITA

OKLAHOMA

Employment Application

The City of Vinita is an Equal Opportunity Employer

DIRECTIONS: Type or print using black ink. Sign the completed application. Attach supplemental sheets if needed.

RESUME NOTE: Employment Record, Education & References sections optional if details are present in attached resume.

COMPLETENESS: Ensure all fields not present in resume are filled in to ensure full application consideration.

General Information

Last Name *

First Name *

Middle Name

Social Security Number *

Date of Application *

Present Address (Street, City, State, Zip Code) *

Contact Address (If different from present address)

Phone No. - Day *

Phone No. - Evening

Alternate Phone No.

Birth Date (Required ONLY if under 18)

If Hired, Can You Provide Proof of Citizenship or Legal Right to Work? *

Yes No

Are you related to any employee, officer or elected official of the City of Vinita / Vinita Utilities Authority?

Yes No

Have You Previously Worked for the City of Vinita?

Yes No

Have you ever been convicted of any criminal offense other than minor traffic violations?

A criminal conviction will be considered only in relation to the job for which you are applying. Seriousness and nature of the offense, time elapsed, and rehabilitation will be taken into consideration.

Yes No

Position Desired

Type of Position Applying For *

How Did You Learn About The Position?

Advertisement Friend Walk-In Agency Relative Other

Employment Record

List Most Recent Employment First

Note: If your attached resume provides all work history details, you may leave non-essential fields blank.

Employer 1 (Most Recent)

Employer

Supervisor's Name

Reason for Leaving

Street Address, City, State, Zip Code

Phone

Start Date

End Date

Final Position Title

Final Salary

Position Description

May we Contact This Employer? Yes No

Employer 2

Employer

Supervisor's Name

Reason for Leaving

Street Address, City, State, Zip Code

Phone

Start Date

End Date

Final Position Title

Final Salary

Position Description

May we Contact This Employer? Yes No

Employer 3

Employer

Supervisor's Name

Reason for Leaving

Street Address, City, State, Zip Code

Phone

Start Date

End Date

Final Position Title

Final Salary

Position Description

May we Contact This Employer? Yes No

Employer 4

Employer

Supervisor's Name

Reason for Leaving

Street Address, City, State, Zip Code

Phone

Start Date

End Date

Final Position Title

Final Salary

Position Description

May we Contact This Employer? Yes No

Education & Training

Education Level	Yrs. Completed	Field of Study	Graduate or Degree
High School
College / University
Business / Technical
Other

Relevant Skills, Licenses & Certifications

List Licenses, Foreign Languages, Computer, Data/Word Processing, Office Equipment, Typing, Shorthand, or Other Skills. Please indicate Professional License Number and State of Issuance.

Specialized Training, Apprenticeship, Skills & Extracurricular Activities

U.S. Military Job-Related Training

Professional, Trade, Business, Honors, Certifications or Civic Activities and Offices Held

You may exclude memberships which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

Language Ability

List languages you could use in your work and check applicable capabilities:

Language	Speak	Read	Write
English

References

List three persons, other than relatives or personal friends, who have knowledge of your work experience and/or education.

Reference 1

Name / Title

Mailing Address

Phone

Reference 2

Name / Title

Mailing Address

Phone

Reference 3

Name / Title

Mailing Address

Phone

Authorization & Certification

Application Must Be Signed Prior to Submitting

I hereby authorize investigation of all statements contained in this application and on my resume, if provided. I certify that such statements are true, and understand that misrepresentation or omission of facts called for in this form, or on any resume provided by me, is cause for termination of employment without notice.

I also agree to such examination by a physician as may be required, employment being contingent on the satisfactory passing thereof.

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. It is further understood that this "at will" employment relationship may not be changed by any authorized executive of this organization. I understand that I am required to abide by all rules and regulations of the employer.

Applicant Signature * (Draw inside box or type below)

Or Type Full Name as Digital Signature:

Date *

Equal Employment Opportunity (Optional & Confidential)

Voluntary

All employers are required to provide equal employment opportunity, and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional, and failure to provide it will have no effect on your application for employment. If you are selected to fill the position for which you are applying, you will be required to provide the employer with your date of birth for insurance purposes.

Ethnicity (check one definition below):

White Black / African American Hispanic Asian / Pacific Islander Native American / Alaskan

Ethnicity Definitions:

Asian / Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands. Area includes China, Japan, Korea, the Philippine Islands, Samoa, etc.

Native American / Alaskan: All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

White (not of Hispanic origin): All persons having origin in any of the original peoples of Europe, North Africa or the Middle East.

Black / African American (not of Hispanic origin): All persons having origins in any of the black racial groups.