* Position:

Position:

Position:

Drivers License #:

State:

Expiration Date:

License Class:

Endorsement:

* Have you ever received three (3) or more convictions for moving traffic violations during the last 36 months (3 years)?

* Have you received a Driving While Intoxicated (DWI) or Driving Under Influence (DUI) citation during the last 36 months (3 years)?

* Is your driver’s license currently suspended?

* Are you currently employed by the City of Pine Bluff?

If Yes, please indicate your Department/Division:

* Are you a former employee of the City of Pine Bluff?

If Yes, please indicate the Last Date(s) of Employment and Department/Division

* Have you ever been discharged or forced to resign from a position?

If yes, please indicate Employer, Date and Reason.

* Do you have any relatives working for the City of Pine Bluff?

If yes, please indicate Name, Relationship and Department.

* Have you ever been convicted of a
felony?(Excluding those records that
have been expunged, eradicated, sealed,
or disposed of in Juvenile Court).
CONVICTION IS NOT AN AUTOMATIC
BAR TO EMPLOYMENT.

If Yes, please indicate Nature of Offense, Name and Location and Date of Conviction

* Highest Grade Completed (Choose
One)

* Did you graduate from High School or obtain a GED?

* Name and Location of last school attended. (High School, Jr. High, etc…)

For School/Training 1, please list: Name & Location of School, Dates Attended (To/From), Course/Subjects Completed and Diploma/Certificate Received.

For College/University 1, please indicate: Name & Location of School, Dates Attended (To/From), Type of Degree (BA/BS/MA/PhD), and Major.

For Professional License 1, please indicate: Organization Issued By, Field/Trade Specialization, License #, Issue Date/Expiration Date.

Please indicate any additional skills by checking below.

If you answered Typing, please indicate your WPM:

Do you have any Other skills that are applicable to this job?

(Excluding Former Employees and Relatives)
Note: Please complete ALL information on personal references.

* Name:

* Address:

* Telephone:

* Years Known:

(Excluding Former Employees and Relatives)
Note: Please complete ALL information on personal references.

* Name:

* Address:

* Telephone:

* Years Known:

(Excluding Former Employees and Relatives)
Note: Please complete ALL information on personal references.

* Name:

* Address:

* Telephone:

* Years Known:

(Excluding Former Employees and Relatives)
Note: Please complete ALL information on personal references.

* Name:

* Address:

* Telephone:

* Years Known:

* Have you ever served in the armed forces?

If so what branch?

What were your duties? (Include Special Training and Duty Station(s))

Have you had any schooling under the G.I. Bill of Rights?

If yes, please describe.

* Can we contact your present employer?

* Starting Date
(MM/YY)

* Ending Date
(MM/YY)

* Employer/Company Name and Address
(City and State Required)

* Work Status:

* Hours Per Week:

* Name and Title of Immediate Supervisor:

* Telephone #

* Fax #

* Starting Salary:

* Ending Salary:

* Reason for Leaving:

Position Held:

* Describe job responsibilities:

Starting Date
(MM/YY)

Ending Date
(MM/YY)

Employer/Company Name and Address
(City and State Required)

Work Status:

Hours Per Week:

Name and Title of Immediate Supervisor:

Telephone #

Fax #

Starting Salary:

Ending Salary:

Reason for Leaving:

Position Held:

Describe job responsibilities:

Starting Date
(MM/YY)

Ending Date
(MM/YY)

Employer/Company Name and Address
(City and State Required)

Work Status:

Hours Per Week:

Name and Title of Immediate Supervisor:

Telephone #

Fax #

Starting Salary:

Ending Salary:

Reason for Leaving:

Position Held:

Describe job responsibilities:

Starting Date
(MM/YY)

Ending Date
(MM/YY)

Employer/Company Name and Address
(City and State Required)

Work Status:

Hours Per Week:

Name and Title of Immediate Supervisor:

Telephone #

Fax #

Starting Salary:

Ending Salary:

Reason for Leaving:

Position Held:

Describe job responsibilities:

Starting Date
(MM/YY)

Ending Date
(MM/YY)

Employer/Company Name and Address
(City and State Required)

Work Status:

Hours Per Week:

Name and Title of Immediate Supervisor:

Telephone #

Fax #

Starting Salary:

Ending Salary:

Reason for Leaving:

Position Held:

Describe job responsibilities:

* Last Name:

* First Name:

* Middle:

* City:

* State:

* Zip:

* Social Security Number:

* Driver’s License No:

* State Driver’s License Issued In:

* Date of Birth:

* Maiden or Other Name(s) Used

Last:

First:

Middle:

I hereby give my permission for the City of Pine Bluff to obtain information relating to
my criminal history through the Pine Bluff Police Department, the District Courts of
Jefferson County, the State and Nation. The criminal history record may include arrest
and conviction data as well as plea bargains and deferred adjudications. I understand
that this information will be used, in part, to determine my employment eligibility with
the City of Pine Bluff.

* Signature of Applicant

* Date

The City of Pine Bluff is an Equal Opportunity Employer. We ask that you voluntarily provide
the following information which will be used to study recruitment and employment patterns and
to provide, as requested, that statistical data to certain federal compliance agencies. This
information WILL NOT be used in the employment process; and failure to provide the
information WILL NOT jeopardize your opportunity for employment with the City of Pine Bluff.

Date:

Name:

Title of job(s) for which you have applied:

Sex:

Race/Ethnic
Please check the category which identifies your race/ethnic background.

I understand that I am protected by various laws prohibiting discrimination of the basis of race, color, national origin, sex, religion, age (if over the age of 40) and, in some circumstances, disability, veteran status. I further understand that the information contained in this form is to be used solely in equal employment record keeping, reporting and other legal requirements. I also understand that the information will be kept in the strictest of confidence and will not be disclosed to others except for this above stated purpose and then only if necessary.

Signature of Applicant

Date

NOTE: The information provided on this form will be kept separate from the employment application form.