Town of Murfreesboro

Town of Murfreesboro

P.O. Box 6, Murfreesboro, NC27855-0006

Office: 252.398.5904 Fax: 252.398.5973

Website: e-mail:

Applicant Information

Last Name / First / M.I. / Date
Street Address / Apartment/Unit #
City / County / Postal Code
Phone / E-mail Address
Date Available / Social Security No. / Desired Salary
Position Applied for
Are you a citizen of the United States? / YES / NO / If no, are you authorized to work in the United States? / YES / NO
Have you ever worked for this company? / YES / NO / If so, when?
Have you ever been convicted of a felony? / YES / NO / If yes, explain

Education

High School / Address
From / To / Did you graduate? / YES / NO / Degree
College / Address
From / To / Did you graduate? / YES / NO / Degree
Other / Address
From / To / Did you graduate? / YES / NO / Degree

References

Please list three professional references.
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address

Previous Employment

Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO

Military Service

Branch / From / To
Rank at Discharge / Type of Discharge
If other than honorable, explain

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature / Date

TO WHOM IT MAY CONCERN:

I have made application for employment with the Town of Murfreesboro, and I am aware that my previous employment record, medical history background, credit records and educational background are to be investigated.

I hereby authorize any of my previous employers, any physician or institution, and the personnel of any education institution to make available a copy of my complete personnel record, medical history record, my credit record, my complete school record, including transcripts of my academic record, to the Town of Murfreesboro upon request of this release or copy thereof.

I authorize any financial institution to disclose any information requested concerning loan amounts and loan payment history, and any information requested concerning accounts with a line of credit intended to prevent overdrafts, to a representative of the Town of Murfreesboro. This provision regarding financial institutions is effective on the date executed and remains in effect for 90 days. I understand that I have the right to revoke this release before any financial records are disclosed upon notification of the relevant financial institution of my revocation.

______

Signature of Applicant

______

Date

Sworn to and subscribed before me this ______day of ______, 20_____.

______

Notary Public

My Commission Expires: ______