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2. 
4. Position applied for must be specified.
6. Position applied for*
8. Date of application *
   Date of application
10. Referral Source:

    1. City Website
    2. Indeed
    3. Facebook

    1. Private Employment Agency
    2. Walk-in
    3. Other
11. Referral Source
13. Type of employment desired*

    1. Full Time
    2. Part Time

    1. Temporary
    2. Seasonal
15. Last Name*
16. First Name*
17. Middle
19. Address1*
21. City
22. State
23. Zip
25. Phone Number*
26. Alternative Phone Number
27. Email Address
29. May we contact you at work?*

    1. Yes

    1. No
31. If yes, work number and best time to call?
33. If necessary; best time to call you at home is?
35. If you are under 18 and it is required can you furnish a work permit?*

    1. Yes

    1. No
37. Have you submitted an application before?*

    1. Yes

    1. No
39. Are you legally eligible for employment in this country?*

    1. Yes

    1. No
41. Date available for work*
    Date available for work
42. What is your desired salary range?*
44. Will you travel if the job required it?*

    1. Yes

    1. No
46. Are you able to meet the attendance requirements of the position?*

    1. Yes

    1. No
48. Will you work overtime if required?*

    1. Yes

    1. No
50. Have you ever been convicted of a crime?*

    1. Yes

    1. No
52. If so, please provide dates and details
    Answering “yes” to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
54. Please provide driver’s license number.
55. State
59. School(city & state)
60. Achieved
    -- Select One --GEDDiplomaDegree
61. Number of years completed
63. Major
64. GPA/Class rank
68. School(city & state)
69. Achieved
    -- Select One --GEDDiplomaDegree
70. Number of years completed
72. Major
73. GPA/Class rank
77. School(city & state)
78. Achieved
    -- Select One --GEDDiplomaDegree
79. Number of years completed
81. Major
82. GPA/Class rank
86. The Employment History section of this application must be completed. Incomplete applications will not be considered.
    Starting with you most recent employer, assignments or volunteer activities, provide the following information.
88. Employer
89. Position
91. Supervisor
92. Phone Number
94. Address
96. Responsibilities
98. Employed From - To (Date)
99. Salary
101. Reason for leaving
103. May we contact for a reference?*

     1. Yes

     1. No
107. Employer
108. Position
110. Supervisor
111. Phone Number
113. Address
115. Responsibilities
117. Employed From - To (Date)
118. Salary
120. Reason for leaving
122. May we contact for a reference?*

     1. Yes

     1. No
126. Employer
127. Position
129. Supervisor
130. Phone Number
132. Address
134. Responsibilities
136. Employed From - To (Date)
137. Salary
139. Reason for leaving
141. May we contact for a reference?*

     1. Yes

     1. No
145. Employer
146. Position
148. Supervisor
149. Phone number
151. Address
153. Responsibilities
155. Employed From-To (Date)
156. Salary
158. Reason for leaving
160. May we contact for a reference? *

     1. Yes

     1. No
164. Skills

     1. Access
     2. Excel

     1. Internet

     1. Powerpoint

     1. Word
166. Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.
170. Please list three professional references.
172. Full Name*
173. Relationship*
174. Years Known*
176. Title*
177. Phone Number*
181. Full Name*
182. Relationship*
183. Years Known*
185. Title*
186. Phone Number*
190. Full Name*
191. Relationship*
192. Years Known*
194. Title*
195. Phone Number*
199. List professional, trade, business or civic associations and any offices held.
     Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.
201. List special accomplishments, publications, awards, etc.
     Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any similarly protected status.
203. List any additional information you would like us to consider.
205. List names and relationship of any relatives currently employed by the City of Rogers.
207. Upload Your Resume
209. Applicant Statement
     I certify that all information I have provided in order to apply for and secure work with the employer is true, complete, and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law. I understand that this application remains current for only 30 days. 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 to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
211. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (I) cancel further consideration of this application, or (II) immediately discharge me from the employer’s service, whenever it is discovered.
213. NOTICE:
     All applications and resume submissions are subject to disclosure upon request under the Arkansas Freedom of Information Act.
215. 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.
217. Applicant Signature*
218. Date*
     Date
Leave This Blank:


220. 1. Receive an email copy of this form.
221. Email address

     This field is not part of the form submission.

222. Submit Submit and Print

* indicates a required field