The City of Macomb, Illinois

232 E. Jackson Street · Macomb, Illinois 61455

This application cannot be partially completed and saved. Please have all work history and other information accessible before entering data. Once the application is complete, be certain to read the "Waiver" section at the bottom of the form. If in agreement with the terms of the waiver, select "I accept." Then select "Submit" at the bottom of the form.

Full Name:

Address:

City:

State:

Zip:

Phone:

Email:

Employment Desired
Specify the job/department you are seeking and date you can start:

Do you have a valid drivers license? Yes No

If No, explain:

Have you received a high school diploma or GED? Yes No

Have you ever applied with the City before? Yes No

If yes, when and for what position?

Are you currently employed? Yes No

May we inquire with your employer? Yes No

Are you currently on "lay-off" status and subject to recall? Yes No

Are you at least 18 years of age? Yes No

Have you been convicted of committing a crime? Yes No
Conviction will not necessarily disqualify an applicant.

If yes, explain:

Are you prevented from lawfully becoming employed in this country because of Visa or immigration status? Yes No
Proof of citizenship will be required upon employment

If yes, explain:

EDUCATION

High School / GED
Name of School
Location of School
Did You Graduate?	Yes No

College
Name of School
Location of School
Did You Graduate?	Yes No

Other Training
Name of School
Location of School
Did You Graduate?	Yes No

Specify any specialized training, apprenticeship, skills and extra-curricular activities:

Describe any honors you have received:

State any additional information you feel may be helpful in considering your application:

List any special skills and qualifications (summarize special job-related skills and qualifications acquired from employment or other experience):

EMPLOYMENT EXPERIENCE
Start with most recent employer:

Employer 1

Employer
Address
Job Title
Supervisor
Employment Began
Employment Ended
Hourly Rate Beginning
Hourly Rate Ending
Reason for Leaving
Work Performed

Employer 2

Employer
Address
Job Title
Supervisor
Employment Began
Employment Ended
Hourly Rate Beginning
Hourly Rate Ending
Reason for Leaving
Work Performed

Employer 3

Employer
Address
Job Title
Supervisor
Employment Began
Employment Ended
Hourly Rate Beginning
Hourly Rate Ending
Reason for Leaving
Work Performed

Employer 4

Employer
Address
Job Title
Supervisor
Employment Began
Employment Ended
Hourly Rate Beginning
Hourly Rate Ending
Reason for Leaving
Work Performed

MILITARY SERVICE

Branch
From	to Discharge Date
Type of Discharge
Are you drawing any military benefits?	Yes No
If yes, please describe

REFERENCES

Name
Address
Business
Years Known

Name
Address
Business
Years Known

Name
Address
Business
Years Known
Waiver and Release I hereby certify that the information contained in this application is correct to the best of my knowledge. If any material facts in this application are untrue, I understand that I may lose all rights to any job with the City of Macomb, Illinois. I authorize the City of Macomb to undertake a personal history investigation into the contents of this application. I release the City of Macomb from all liability for damages which may occur as a result of the usage of this employment information. I understand a physical examination and drug screen may be required prior to beginning employment. I also understand that upon commencing employment, I will be required to maintain permanent residence within the boundary lines of McDonough County, Illinois. After you have read the above Waiver and Release, check one of the following buttons: I accept the above written Waiver and Release I do not accept the above written Waiver and Release

Phone (309) 833-2575 · Fax (309) 836-1090 · staff@CityofMacomb.com