=== Page 1 === Application for Employment Return to: Human Resources - Village of Westchester 10300 Roosevelt Road Westchester, IL 60154 Email: hr@westchester-il.gov (708) 345-0020 Thank you for applying with the Village of Westchester! Your application will be considered without regard to race, color, sex, age, national origin, handicap, disability, marital status or any other status that is protected by federal, state and local law. All information in or connected with this application will be treated as confidential to the extent practicable. Equal access to programs, services and employment is available to all persons. Please complete the entire application or indicate "not applicable" where appropriate. Incomplete applications may be subject to rejection. Disclaimer: Relatives of elected or appointed Village officials, or current Village employees are ineligible for employment with the Village where employment would or could reasonably be expected to result in a situation to create a potential or actual conflict of interest or actual or perceived favoritism, in accordance with our employment policies and practices. Due to the number of applications the Village receives, the Village is unable to contact all applicants. You will be contacted directly if you are chosen as an interview candidate. Any offer of employment is also contingent upon successful completion of an employment and criminal background check, satisfactory reference check, and a post- conditional offer physical exam and drug screening test. GENERAL INFORMATION Full Name:___________________________________________ Phone Number: ______________________________ Email Address: ____________________________________________________________________________________ Address:_________________________________________________________________________________________ Street City State Zip Code Do you have a valid driver’s license? Yes No If yes, please provide: License Class _______ Issuing State:____ If necessary, best time to call you is: _________ AM PM Are you 18 years of age or older? Yes No Are you related to any employee of the Village of Westchester or an elected official? Yes No If yes, state their name and relationship to you: __________________________________________________________ Have you ever been previously employed by the Village of Westchester? Yes No N/A If yes, please state when and in what position:___________________________________________________________ Are you prevented from lawfully being employed in this country because of Visa or Immigration Status? Yes No Proof of citizenship or immigration status will be required upon employment === Page 2 === POSITION INFORMATION Position Applying for: ______________________________________ Date available for work:____________________ Will you work overtime, if required? Yes No If no, please explain:___________________________________ Have you ever been convicted of, or pled guilty or nolo contendere to, any crime other than a minor traffic violation? Note to applicant: When answering this question, you are not obligated to disclose sealed or expunged records of conviction or arrest, nor are you obligated to disclose expunged juvenile records of adjudication or arrest. Yes No If yes, please provide dates and details: __________________________________________________ _________________________________________________________________________________________________ Answering yes to the above question does not constitute an automatic bar to employment. Factors such as the date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. Please indicate by checking the appropriate box how you heard about the position for which you are applying: Village website Village Employee Job Website (which one?) _____________________________________ Other:_________________________________________________________________________________________ EDUCATIONAL BACKGROUND Starting with your most recent school attended, provide the following information: Name of Institution Years Degree Type or Major(s)/ Graduated? (incl. city and state) Completed Diploma Minor(s) (Yes / No) === Page 3 === SKILLS AND QUALIFICATIONS Please summarize any special training, skills, licenses (including current CDL class of license if applicable), and/or any certificates you would like to highlight as part of our application review process that may assist you in performing the position for which you are applying: RELATED INFORMATION To what job-related organizations (professional, trade, etc.) do you belong? List special accomplishments, publications, awards, etc. Is there any other job-related information you want us to know about you? === Page 4 === EMPLOYMENT HISTORY Starting with your most recent employer, please provide the following information. If additional space is required, please attach additional sheets, utilizing the same format. Employer:____________________________________________________ Telephone #:_________________________ Street Address:_______________________________________ City:_____________________________State:______ Starting job title/final job title: ________________________________________________________________________ Dates Employed:___________ to___________May we contact Employer for reference? Yes No Later Note: Current employers will only be contacted for reference if a conditional offer of employment is given Immediate supervisor and title (for most recent position held):______________________________________________ E-mail:___________________________________________________________________________________________ Why did you leave or looking to leave? _________________________________________________________________ Summarize the type of work performed and job responsibilities:____________________________________________ _________________________________________________________________________________________________ What did you like most about your position?____________________________________________________________ What were the things you liked least about the position?__________________________________________________ Employer:____________________________________________________ Telephone #:_________________________ Street Address:_______________________________________ City:_____________________________State:______ Starting job title/final job title: ________________________________________________________________________ Dates Employed:___________ to___________May we contact Employer for reference? Yes No Later Note: Prior Employers will only be contacted for reference if a conditional offer of employment is given Immediate supervisor and title (for most recent position held):______________________________________________ E-mail:___________________________________________________________________________________________ Why did you leave or looking to leave? _________________________________________________________________ Summarize the type of work performed and job responsibilities:____________________________________________ _________________________________________________________________________________________________ What did you like most about your position?____________________________________________________________ What were the things you liked least about the position?__________________________________________________ === Page 5 === EMPLOYMENT HISTORY - CONTINUED Employer:____________________________________________________ Telephone #:_________________________ Street Address:_______________________________________ City:_____________________________State:______ Starting job title/final job title: ________________________________________________________________________ Dates Employed:___________ to___________May we contact Employer for reference? Yes No Later Note: Prior Employers will only be contacted for reference if a conditional offer of employment is given Immediate supervisor and title (for most recent position held):______________________________________________ E-mail:___________________________________________________________________________________________ Why did you leave or looking to leave? _________________________________________________________________ Summarize the type of work performed and job responsibilities:____________________________________________ _________________________________________________________________________________________________ What did you like most about your position?____________________________________________________________ What were the things you liked least about the position?__________________________________________________ Employer:____________________________________________________ Telephone #:_________________________ Street Address:_______________________________________ City:_____________________________State:______ Starting job title/final job title: ________________________________________________________________________ Dates Employed:___________ to___________May we contact Employer for reference? Yes No Later Note: Prior Employers will only be contacted for reference if a conditional offer of employment is given Immediate supervisor and title (for most recent position held):______________________________________________ E-mail:___________________________________________________________________________________________ Why did you leave or looking to leave? _________________________________________________________________ Summarize the type of work performed and job responsibilities:____________________________________________ _________________________________________________________________________________________________ What did you like most about your position?____________________________________________________________ What were the things you liked least about the position?__________________________________________________ === Page 6 === EMPLOYMENT HISTORY - CONTINUED Please explain any gaps in your employment, other than those due to personal illness, injury or disability: Have you ever been involuntarily terminated or asked to resign from a job? Yes No If “Yes”, please explain: REFERENCES List names and telephone numbers of three to five business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. Note to Applicant: references provided will only be contacted for a reference if a conditional offer of employment is given. Name Title Phone E-mail # of Years Number Known === Page 7 === APPLICANT STATEMENT I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and accurate. I understand that this application remains current for only six months. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. This application does not constitute an agreement or contract for employment. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the Village Manager or his/her designee. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. The Village does not tolerate unlawful discrimination in its employment or hiring practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state, or local law. EMPLOYMENT WITH THE VILLAGE OF WESTCHESTER IS ON AN ‘AT-WILL’ BASIS (i.e.: an employee may resign at any time and the Village may discharge the employee at any time with or without notice, and with or without cause.) I understand that a post-offer medical examination, including a drug screen, will be required for this position. I further understand that any information provided by me that is found to be false, incomplete, inaccurate, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered. In consideration of the Village reviewing and investigating this application I hereby waive, to the greatest extent permitted by law, any and all suits, claims, actions or demands in law, chancery or administrative proceeding and damages, costs, expenses, lost wages, lost income or lost opportunities which may result from the Village's withdrawal of any offer of employment. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement. Signature of Applicant:________________________________________________ Date:_________________________ APPLICANT CONSENT FOR BACKGROUND AND CRIMINAL HISTORY CHECK Note to Applicant: Background and Criminal History Check will only be conducted if a conditional offer of employment is given. I, the undersigned, hereby authorize the release of any employment history, criminal history, police contact, credit bureau and driving record information that may exist regarding me from any agency, organization, institution, or entity having such information on file. I am aware and understand that my fingerprints will be taken and used to check the criminal history record information files of the Illinois State Police and the Federal Bureau of Investigation. I further understand that I have the right to challenge any information disseminated from these criminal justice agencies regarding me that may be inaccurate or incomplete. DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE CONSENT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Consent For Background And Criminal History Statement. Signature of Applicant:________________________________________________ Date:_________________________