Select Department you are Applying to * - Select -Parks DepartmentStreet DepartmentWastewater DepartmentWater Works Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Last Name * First Name * Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP * Phone Number * Email Address Are you at least 18 years of age? * Yes No Preferred Method of Contact: * Text Email Call Do you have any friends or relatives employed by the Town of Speedway? Yes No If yes, please provide names Desired Rate of Pay? $ Available Start Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year The Immigration Reform and Control Act of 1986 requires us to inspect documents verifying the identity and employment eligibility of all new hires. Are you legally authorized to work in the United States? * Yes No Have you ever been convicted of a crime? (other than a traffic misdemeanor) * Yes No If yes please list: where, when, the nature of the offense and disposition of your case. Have you ever served in the Armed Forces of the United States? If yes, please answer the following: Branch Location Date of Service Select below what type of employment hours you are applying for. * Full Time Part Time Summer Help Shift Preference Have you ever been employed by the Town of Speedway? * Yes No If yes, identify date of prior employment, positions held, supervisor(s) and reason(s) for leaving For applications applying for positions involving driving a municipal owned vehicle Do you have a valid Indiana drivers license?* * Yes No Driver's License Number * CDL Number and Expiration Date Chauffeur and Expiration Date Other Number and Expiration Date EducationPlease list - 1) Name of School 2) Major or Area of Study 3) Diploma, Degree or Certificate obtained High School Community College or Trade School College or University Graduate School List any classes, completed academic honors, additional skills or training which may be applicable to position for which you are applying. Business, Educational or Professional References: Previous Supervisors PreferredPlease list the Name, Company, Telephone and Years known for references listed First Reference Second Reference Employment History starting with present or most recentPlease list Company Name and Address, Telephone, Dates of Employment, Salary , Job Description or Duties Employment #1 May we contact? Yes No Employment #2 May we contact? Yes No Employment #3 May we contact? Yes No I certify that information provided in this application is true and complete. I understand that if I have provided false or misleading information I will be disqualified for consideration, and if hired can be subject to discharge. I authorize the Town of Speedway to contact my present and former employees for verification of information I provided in this application unless indicated above. I hereby release the Town of Speedway from any liability for any damages that could result from furnishing information provided in the application. I understand that the Town of Speedway may require me to take a pre-employment drug screening test as a condition of employment and if I refuse or fail the screening test I will be disqualified for consideration for employment. Electronic Signature * To certify your application, provide an electronic signature (type your name in field provided above). Leave this field blank
