Fillable Printable Employment Application - City of Wilmington, Delaware
Fillable Printable Employment Application - City of Wilmington, Delaware
Employment Application - City of Wilmington, Delaware
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City of Wilmington
Delaware
EMPLOYMENT APPLICATION
FOR HUMAN RESOURCES USE ONLY
MQ’s
Yes No
Comments:
Rater:
Date:
Please Type or Print Clearly
POSITION DESI RED:
ANNOUNCEMENT #:
NAME:
SOCIAL SECURITY NO.
(Last) (First) (MI)
ADDRESS:
(Street) (City) (State) (Zip Code)
TELEPHONE: Home:
Work: Cell: Email:
May we call you at work?
Yes
No
IN CASE OF EMERGENCY NOTIFY:
(Name) (Phone)
Can you, after em ployment, submit verification of y our legal right to work in the United States?
Yes No
Have you applied for this position within the last six months?
Yes No Check the Type( s ) of Employm ent: Regular Part-Time Seasonal
Education Intern Temporary
Have you ever been employed by the City?
Yes No If yes, when:
If under age 18, can y ou furnish a work permit?
Yes No If no, explain:
If a license or certificate is a requirement of this position, give the following information:
Title:
State: _______________________ Class:
Date Issued:
Date Expired:
Driver’s License Nu mber:
CDL Class:
Languages other than E nglish spoken:
EDUCATION
CHECK HIGHEST GRADE COMPLETED:
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7
(College) (Grad)
DO YOU HAVE A HIGH SCHOOL EQUIVALENCY CERTIFICATE (GED)?
Yes No
NAME AND LOCATION
DATES ATTENDED
Month & Year
From To
GRADE
POINT
AVERAGE
DIPLOMA
OR DEGREE
RECEIVED
MAJOR
SUBJECT
MINOR
SUBJECT
High School
College or
University
Grad School
(Transc ripts may
be require d)
Other
An Equal Opportunity Employer
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EMPLOYMENT EXPERIENCE
THE INFORMA T ION YOU PROV I D E, ALO NG WIT H EDUCATION, WILL B E USED TO ASSIST IN DETERMIN ING IF YOU ME ET TH E MINIMUM
QUALIFICATIONS AND PLACEMENT ON THE REGISTER FOR THE POSITION YOU ARE SEEKING. GIVE A COMPLETE RECORD: PART-TIME WORK,
MILITARY SERVICE, AND VOLUNTEER EXPERIENCE MAY BE INCLUDED. FOR PART-TIME OR VOLUNTEER WORK, INDICATE NUMBER OF HOURS
WORKED WEEKLY. INDICATE DATES (MONTH AND YEAR BEGINNING AND ENDING) OF EACH POSITION HELD AND A DESCRIPTION OF DUTIES
PERFORMED FOR EACH. EMPLOYMENT RECORD SHOULD BE RELATIVE TO DESIRED POSITION.
NAME ON EMPLOYMENT RECORDS/EDUCATIONAL RECORDS IF DIFFERENT FROM PRESENT.
NAME:
EMPLOYMENT EXPERIENCE -- START WITH YOUR PRESENT OR LAST JOB
NAME OF EMPLOYER
ADDRESS
EMPLOYED (Month & Year) FROM
TO ANNUAL PAY RATE: START FINISH
REASON FOR LEAVING:
SUPERVISOR:
PHONE NO:
FULL-TIME JOB TITLE AND DUTIES:
PART-TIME
Hrs. Per Week
NAME OF EMPLOYER
ADDRESS
EMPLOYED (Month & Year) FROM
TO ANNUAL PAY RATE: START FINISH
REASON FOR LEAVING:
SUPERVISOR:
PHONE NO:
FULL-TIME JOB TITLE AND DUTIES:
PART-TIME
Hrs. Per Week
NAME OF EMPLOYER
ADDRESS
EMPLOYED (Month & Year) FROM
TO ANNUAL PAY RATE: START FINISH
REASON FOR LEAVING:
SUPERVISOR:
PHONE NO:
FULL-TIME JOB TITLE AND DUTIES:
PART-TIME
Hrs. Per Week
NAME OF EMPLOYER
ADDRESS
EMPLOYED (Month & Year) FROM
TO ANNUAL PAY RATE: START FINISH
REASON FOR LEAVING:
SUPERVISOR:
PHONE NO:
FULL-TIME JOB TITLE AND DUTIES:
PART-TIME
Hrs. Per Week
NAME OF EMPLOYER
ADDRESS
EMPLOYED (Month & Year) FROM
TO ANNUAL PAY RATE: START FINISH
REASON FOR LEAVING:
SUPERVISOR:
PHONE NO:
FULL-TIME JOB TITLE AND DUTIES:
PART-TIME
Hrs. Per Week
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QUALIFICATIONS SUMMARY
In the space provided below, summarize your education, training, and experience relative to the qualifications and selective requirements as described on the job
announcement.
USE ADDITIONAL PAGES IF NECESSARY
MILITARY
Present Classification:
Reserve Status: Active Inactive Other
U.S. Military Service
USA - USN - USAF - USMC - etc.
Branch Specialty
ACTIVE DUTY DATES
From To
Rate/Rank
Reason for Leaving:
PROFESSIONAL REFERENCES
NAME BUSINESS RELATIONSHIP TELEPHONE
YEARS
KNOWN
1.
2.
3.
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INFORMATION FOR APPLICANTS
HOW TO APPLY
– Applications for employment should be submitted on official application forms to the Department of Human Resources, City/County
Building, 800 French Street, Fourth Floor, Wilmington, Delaware 19801. Applications may be faxed to (302) 571-4298 or emailed to
[email protected]. Submit one application for each position announced for which you feel you are qualified. It is your responsibility to submit
your applications by the closing date and to keep your application up to date.
An application may be rejected if not complete or if not filed prior to the closing date specified on the job vacancy announcement. An applicant whose
application is rejected shall be notified of such rejection.
ELIGIBLE LISTS
– Applicants who meet certain requirements and who are successful in the phases of the examination process may be placed on an eligible
list for six months. Applicants should not assume that receiving a notice of eligibility assures employment.
ADA
– Accommodations are available for applicants with disabilities in all phases of the application and employment process.
FOR FURTHER INFORMAT ION – Call or visit the Department of Human Resources in the City/County Building, Fourth Floor, 800 French Street,
Wilmington, Delaware 19801 (302) 576-2460.
TERMS AND CONDITIONS OF EMPLOYMENT (Ple ase read carefully before signing)
Ownership of Work Product
. I understand that except as is otherwise specified all copyrights, patents, trade secrets, or other intellectual property rights
associated with any works of authorship, ideas, concepts, techniques, or inventions developed or created during the course of performing services
(collectively, the “Work Product”) shall belong exclusively to the City of Wilmington and shall, to the extent possible, be considered a work made for hire
for the City of Wilmington within the meaning of Title 17 of the United States Code. All copyrights or other intellectual property rights pertaining thereto
are automatically assigned without any requirement of further consideration to the City of Wilmington.
I understand that all City employees are required to be residents of the City and that if hired, I am required to obtain City residency within six (6) months
of my date of hire and maintain residency for five (5) years of employ ment. It will be my responsibility to keep the Department of Human Resources
advised of any changes of my address and telephone number.
I acknowledge and understand that medical certification is required for employment, per Section 40-54 of the Wilmington City Code. I understand that if
I am selected for employment, I must pass a medical examination given by a physician designated by the Department of Human Resources. I understand
that I will be required to sign a consent form for the drug screening urinalysis as part of the examination. I also understand that failure to pass either the
medical certification or the drug screening urinalysis will result in my not being hired, or subsequently terminated.
I understand that if I am hired by the City of Wilmington, the City shall require verification of my identity and eligibility for employment in the United
States.
I understand that I must successfully complete a probationary period before acquiring regular status.
I certify that if I am a male, born after January 1, 1960, and if required to register, I have registered for Selective Service. I understand that I may be
required to document registration.
APPLICANT’S SIGNATURE:
DATE:
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CITY TO WORK REGISTRY
RELEASE FORM
FOR CITY OF WILMINGTON RESIDENTS ONLY
Pursuant to “City to Work” Substitute No. 1 to Ordinance 13-031, effective November 1,
2013, the City of Wilmington Department of Human Resources is required to compile and
maintain an applicant registry for employment referral purposes (the “Registry”) consisting of
the following individuals: (1) residents of the City of Wilmington as of the date the City of
Wilmington employment application (the “Application”) is submitted to the City; and (2) who
applied for an employment position with the City of Wilmington; but (3) who were unsuccessful
in achieving employment with the City of Wilmington.
With your permission, the City of Wilmington will include your name on the list of
applicants who qualify to be on the Registry along with a copy of your City of Wilmington
Application to temporary employment agencies servicing the City of Wilmington at that given
time (the “Employment Agency”).
By signing this Release, you hereby consent to the City of Wilmington forwarding your
Application to the Employment Agency. You understand that the City of Wilmington is not
promising you employment by the Employment Agency or with the City of Wilmington, and
that the City of Wilmington’s obligations cease after your Application is forwarded to the
Employment Agency. Any follow-up regarding employment with the Employment Agency shall
be made by you directly to the Employment Agency and not to or with the City of Wilmington.
By signing below, you certify that you are a resident of the City of Wilmington and the
information contained on your Application is true and correct. Your signature appearing below
indicates that you understand the abo v e and will be legally bound thereby.
I, , hereby give
permission to the City of Wilmington Department of Human Resources to
forward my name and my Application to the Employment Agency. I understand
that this does not guarantee my employment by the Employment Agency or by
the City of Wilmington.
PLEASE PRINT:
Name:
Address:
Signature Date
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CITY OF WILMINGTON
D
EPARTMENT OF HUMAN RESOURCES
800 North French Street, Louis L. Redding City/County Building, Wilmington, DE 19801
AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION
The City of Wilmington requires, as a condition of employment, and/or continued employment, that all applicants
consent to and authorize a verification of the information submitted on their application or resumé. Please read this
statement carefully.
In consideration for employment and internships, all applicants must consent to and authorize a pre-employment
verification of background information. Consideration for employment is contingent upon the results of this reference and
background investigation, which may include verifications of education and/or employment history; credit history; motor
vehicle records; a review of local, county, state, and federal government agencies and public court records; personal
references; and/or other information as deemed necessary to fulfill the job requirements.
This Authorization and Consent for Release of Information gives my permission to the City of Wilmington and its
designated agent(s), to the full extent permitted by law, to conduct a reference and background investigation. The City will
utilize the results of this process to determine eligibility for employment under the City's employment policies. All
information will be proprietary and kept as confidential as practicable. The information obtained by the City will not be
provided to any parties other than the City.
I, the undersigned, do hereby certify that the information provided by me in my application for employment,
resume, or in verbal discussion relating to my consideration for employment or an internship is true and complete to the
best of my knowledge and understand that omissions and misstatements may be cause for rejection of this application,
removal of my name from eligible list, or discharge from City employment. I hereby authorize the City of Wilmington or
its designated agent to: (1) investigate the truthfulness of all my statements made on my application or resume or verbal
statements made by me in the interview process; (2) conduct any verification of my education, employment, personal and
motor vehicles records, and to receive any criminal conviction history record information relating to me which may be on
file with any local, state, or federal crimin al justice agencies; and (3) disclose verbally or in writing the results of any
investigation with authorized employees or agents of the City involved in the hiring process. I understand that if I am
employed, any false statements will be considered as cause for possible dismissal.
Further, I authorize the procurement of any other information, which relates to my background, character, and
personal reputation, which may be deemed relevant to my employment in accordance with state and federal laws.
I have read and understand this Authorization and Consent for Release of Information form. The original or copy
of this document serves as my valid authorization to any and all persons, educational institutions, past and/or current
employers, organizations, law enforcement or criminal records agencies, and other agencies to release information about
me to the City or its designated agent and hereby release and hold harmless all such persons, institutions, agencies,
employers, and organizations providing such information from liability and any or all claims and damages connected with
providing any requested information.
I further agree to indemnify, discharge, and forever hold harmless the City of Wilmington, its
associates/employees, its designated agen t, its directors, officers, or employees, to the full extent permitted by law, from
any and all damages, claims, losses, liabilities, costs, and expenses (including but not limited to attorney’s fees) incurred as
a direct or indirect result of any lawsuit or administrative proceeding brought against the City of Wilmington, related
directly or indirectly to the disclosure of any such information or so such investigation. I understand that my employment
is conditioned upon a suitable background investigation.
I understand that I have the right to request in writing, within five (5) working days of the hiring decision
notification, a complete an d accurate disclosure of the nature and scope of any investigative report requested on me. If
denied employment wholly or partly because of information contained in a consumer report from a consumer-reporting
agency, I have the right to be advised and supplied with the name and address of the consumer-reporting agency making the
report.
According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied based on
information obtained by my prospective employer, and to receive, upon written request, a disclosure of the public record
information and of the nature and scope of the investigative report. If I am a resident of Minnesota, California, or
Oklahoma only and would like a copy of the investigative report, I will check here.
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I understand that if I am permitted to begin my employment or assignment before the results of a medical
examination, reference check, consumer report, or investigative report are complete; my continued employment is
contingent upon those results, as well as my ability to perform the duties of my position with or without reasonable
accommodation.
Authorized by Candidate:
Print Name (Last, First, Middle) Maiden/Alias Name (if applicable)
Current Address (City, County, State, Zip) How long?
(Please provide all requested information and provide addresses for the last seven years)
Previous Address (City, County, State, Zip) How long?
Previous Address (City, County, State, Zip) How long?
Previous Address (City, County, State, Zip) How long?
Previous Address (City, County, State, Zip) How long?
/ / / / ( ) ( )
Date of Birth Social Security # Home Phone (include area code) Work Phone (include area code)
_________________
Driver License # State / Expiration Date Signature Date
My present employer may be contacted: Yes No
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CITY OF WILMINGTON AFFIRMATIVE ACTION PROGRAM
It is the policy of the City of Wilmington to assure equal and fair treatment in all aspects of employment for minorities, women,
Vietnam-era veterans and disabled veterans, people with physical or mental disabilities, and persons above the age of forty. All
applicants, therefore, are requested to voluntarily provide the following information that is needed to document and assess the
effectiveness of the City of Wilmington’s Affirmative Action Program. This information will be detached and kept separately
from your application and will not be used as a basis for employment decisions.
POSITION APPLIED FOR:
ANNOUNCEMENT #
HOW DID YOU FIND OUT ABOUT THIS POSITION? (Check one)
TV/Channel Newspaper Walk-In Friend
Agency
Other
Employee (Name)
DATE OF BIRTH:
Please check the appropriate area:
VIETNAM-ERA VETERAN DISABLED VETERAN DISABLED
SEX: MALE FEMALE
RACE/ETHNICITY: WHITE BLACK HISPANIC AMERICAN INDIAN
ALASKAN NATIVE ASIAN PACIFIC ISLANDER
Accommodations are available for applicants with disabilities in all phases of the application process. Please call 302-576-2460 to
request assistance prior to the closing date of the job announcement. TDD users should call the DELAWARE RELAY SERVICE number at
1-800-232-5460 for assistance.
PLEASE NOTE: A person with a disability is one who has a verifiable physical or mental impairment, which substantially limits one or more major life activities, or has a record
of such impairment, or is regarded as having such an impairment. Major life activities mean functions such as caring for one’s self, performing manual tasks, walking, seeing,
hearing, speaking, br eathing, learning, and working.
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EMPLOYEE RIGHTS AND RESPONSIBILITIES
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Basic Leave Entitlement
FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons:
• For incapacity due to pregnancy, prenatal medical care or child birth;
• To care for the employee’s child after birth, or placement for adoption or foster care;
• To care for the employee’s spouse, son or daughter, or parent, who has a serious health condition; or
• For a serious health condition that makes the employee unable to perform the employee’s job.
Military Family Leave Entitlements
Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty status in the National Guard or Reserves in support of a
contingency operation may use their 12-week leave entitlement to address certain qualifying exigencies. Qualifying exigencies may include attending certain
military even ts, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certa in counseling sessions, and attending
post-deployment reintegration briefings. FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to
care for a covered servicemember during a single 12-month period. A covered servicemember is a current member of t he Armed Forces, including a m em b er
of the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on active duty that may render the servicemember medically
unfit to perform his or her duties for which the servicemember is undergoing medical treatment, recuperation, or therapy; or is in outpatient status; or is on the
temporary disability retired list.
Benefits and Protec tions
During FMLA leave, the employer must maintain the employee’s health coverage under any “group health plan” on the same terms as if the employee had
continued to work. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and
other employment terms. Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee’s leave.
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at least one year, for 1,250 hours over the previous 12 months, and if at least 50
employees are employed by the employer within 75 miles.
Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight st ay in a medi cal care faci l ity, or
continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee’s job, or
prevents the qualified family member from participating in school or other daily activities. Subject to certain conditions, the continuing treatment requirement
may be met by a period of incapacity of more than 3 consecutive calendar days combined with at least two visits to a health care provider or one visit and a
regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of
continuing treatment.
Use of Leave
An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently or on a reduced leave schedule when medically
nece ssa ry. Employee s must make reasona ble ef forts to sc hedule leave for planned medical treatment so as not to unduly disrupt the employer’s operations.
Leave due to qualifying exigencies may also be taken on an intermittent basis.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In order to use paid leave for FMLA leave, employees
must comply with t h e employer’s normal pa id leave polic ies.
Employee Responsibilities
Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the
employee must provide notice as soon as practicable and generally must comply with an employer’s normal call-in procedures. Employees must provide
sufficient inform ation for the employer to determ ine if the leave may qualify for F M LA protection and the anticipated timing and duration of the leave.
Sufficient informati on may include t hat th e e mpl oyee is unab l e to pe rform j o b functions, the family membe r i s unable to perform daily activities, the need for
hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave. Employees also must inform
the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be required to provide a
certification and periodic recertification supporting the need for leave.
Employer Responsibilities
Covered employers must inform employees requesting leave whether they are eligible under FMLA. If they are, the notice must sp ecify any additional
information required as well as the employees’ rights and responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility.
Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee’s leave
entitlement. If the employer determines that the leave is not FMLA-protected, the employer must notify the employee.
Unlawf ul Ac ts by Employers
FMLA makes it unlawful for any employer to:
• Interfere with, restrain, or deny the exercise of any right provided under FMLA;
• Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to
FMLA.
Enforcement
An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer. FMLA does not affect any Federal
or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave
rights.
For additional information: 1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627 WWW.WAGEHOUR.DOL.GOV
