THE CITY OF FREDERICK PHONE: (301) 694-1885 111 AIRPORT DRIVE EAST FAX: (301) 694-1878 FREDERICK, MARYLAND 21701 JOB LINE: 240-629-6202 FREDERICK POLICE DEPARTMENT PHONE: (301) 694-2133 100 WEST PATRICK STREET FAX: (301) 240-629-6201 FREDERICK, MARYLAND 21701 TDD: (301) 663-3000 http://www.cityoffrederick.com/ APPLICATION FOR EMPLOYMENT

EQUAL EMPLOYMENT OPPORTUNITY: The City of Frederick is an equal employment opportunity employer and shall not discriminate against any applicant because of race, color, religion, gender, national origin, age, disability, marital status, veteran status, or any other legally protected group. We are committed to Affirmative Action.

INSTRUCTIONS: Please typewrite or print in ink all information on this form. Where indicated, check in appropriate spaces. If additional details will be of value in answering these questions, use a separate sheet. False or misleading statements will be cause for rejection or for dismissal after appointment. Note: Physical examination for job requirements and drug testing are required prior to being employed and are paid for by the City. PLEASE COMPLETE THIS APPLICATION IN ITS ENTIRETY.

POSITION APPLIED: _________________________________________ JOB ANNOUNCEMENT # __________________

LAST NAME	FIRST NAME	MIDDLE NAME
STREET ADDRESS
CITY	STATE	ZIP
HOME TELEPHONE NUMBER	CELL PHONE NUMBER	WORK TELEPHONE NUMBER

EDUCATION:

High School

Indicate number of years completed: ___________

q Diploma? Yes No GED? Yes No

Name and location of High School: _______________________________________________

_______________________________________________

College, Vocational, Business, and Graduate Level:

NAME & LOCATION OF SCHOOL

DATES ATTENDED From To

MAJOR SUBJECT

DEGREE

PERSONAL INFORMATION:

Please list any Skills, Certificates, or Equipment experience you possess: _______________

____________________________________________________________________________

If employed, can you verify that you are 18 Years of Age or over? Yes No

If no, do you have a valid Work Permit? Yes No

Are you either a United States Citizen or an Alien who has the Legal Right to Work in the job for which you are applying? Yes No

Pursuant to the Immigration Reform and Control Act of 1986, if you are hired, you must produce, within 72 hours, documents that are specified by the Federal Government, establishing your identity and authorization for employment in the United States.

If applying for a position as a Police Officer,

Can you verify that you are at least 20 ½ Years of Age? Yes No

Can you furnish proof that you are a United States Citizen? Yes No

Have you ever been employed as a Police Officer? Yes No

If yes, where? ________________________________________________________

Have you ever Worked for The City of Frederick? Yes When? ________ No

Do you have a Valid Driver’s License in good standing?

Yes No

Driver’s License #: ________________________ Class of Driver’s License: ________________

State in which issued: ____________________________

Have you been Convicted of any violation of a Federal, State, County, or Municipal law, regulation or ordinance? (Include Military Courts-Martial, traffic arrests, and paid traffic citations. Do not list any criminal charges for which the records have been expunged. Note: This information is used as a tool in consideration for employment. A criminal offense will not necessarily bar employment.)

Yes Date: _________________ No ___________________________

Court: ____________________________ Disposition: _______________________________

If yes, please describe in full: ____________________________________________________

____________________________________________________________________________

Complete for Military Service Experience:

Army Navy Marines Air Force Other __________________

Date of Induction: _______________ Grade, Rating, or Rank: ____________________

Date of Discharge: _______________ Grade, Rating, or Rank: ____________________

Type of Discharge: Honorable Dishonorable Other (Explain):

____________________________________________________________________________

Do you belong to a Reserve Unit? Yes What Unit? ________________________

No

EMPLOYMENT HISTORY: Please complete this section entirely. Provide the following information of your past and current employers, assignments, or volunteer activities, starting with the most recent (use additional sheets if necessary). Explain any gaps in employment. A resume is not required, but may be helpful in the review process.

Name of Employer:
Address:
Telephone Number:
Dates of Employment:	From: To:
Name & Title of Supervisor:
Position Title:
Description of Duties:
Final Salary:
Reason for Leaving:

Name of Employer:
Address:
Telephone Number:
Dates of Employment:	From: To:
Name & Title of Supervisor:
Position Title:
Description of Duties:
Final Salary:
Reason for Leaving:

Name of Employer:
Address:
Telephone Number:
Dates of Employment:	From: To:
Name & Title of Supervisor:
Position Title:
Description of Duties:
Final Salary:
Reason for Leaving:

PERSONAL REFERENCES: (Do not list relatives or employers)

NAME

# YEARS ACQUAINTED

OCCUPATION

DAYTIME PHONE #

May we contact your present employer in reference to your qualifications? Yes No

May we contact your former employers in reference to your qualifications? Yes No

Do you have any friends or relatives working for The City of Frederick? Yes No

If yes, please list their names and your relationship to them:

Name Relationship

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If offered the position, how soon could you start work? ________________________

What is minimum salary you will accept? ___________________________________

IMPORTANT INFORMATION FOR APPLICANT:

(Read carefully before signing. Application must be signed to be considered for employment.)

By my signature below, I agree to the following:

• This application is valid only for the position for which I have applied.
• I authorize investigation of all statements contained in the application. I understand that false or misleading statements or omissions made by me on this application or in connection with this pre-employment process can be sufficient grounds for my rejection as a candidate for employment.
• In accordance with applicable law, I agree to submit to any physical examination requested by the City (including screening for substance abuse), in connection with the processing of my application for employment and further agree to submit to any physical examinations requested by the City during my employment should I be offered and accept a job.
• I understand that if hired, I will be required to furnish proof of identity and authorization to work in the United States.
• I understand that any employment offered by the City of Frederick is of an indefinite duration and that either the City or I may terminate that employment at any time with or without notice for any or no reason or that no agreement to the contrary will be recognized by the City. This statement does not nullify the requirements of the Law Enforcement Officer’s Bill of Rights (LEOBR) for sworn employees of the City.

• Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100.This law DOES NOT APPLY to an individual who applies for employment or is employed as a law enforcement officer or as an employee of a law enforcement agency of the State, a county, or municipal corporation.

Signature: __________________________________________ Date: ___________________

APPLICANT AFFIRMATIVE ACTION DATA

INSTRUCTIONS: The City of Frederick in accordance with Affirmative Action and Equal Employment Opportunity policies is interested in collecting data that will assist us in ensuring a diverse and effective recruitment program.

NOTE: This form will be filed separately from your employment application and will not be used to discriminate in any way in the employment process. The completion of this form is not mandatory; however, your participation is appreciated.

POSITION APPLIED: _________________________________________ JOB ANNOUNCEMENT # __________

LAST NAME

FIRST NAME

MIDDLE NAME

GENDER:

Female

Male

Ethnic Origin: Please check your ethnic origin. Ethnic origin is defined by the Federal Equal Employment Opportunity Commission as follows:

White	(Not of Hispanic Origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Black	(Not of Hispanic Origin) All persons having origins in any of the black racial groups of Africa.
Hispanic	All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Asian/Pacific Islander	All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippines Islands, and Samoa.
American Indian or Alaskan Native	All persons having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliations or community recognition.
Do you have a disability? Yes No The term disability means, with respect to the individual, 1) a physical or mental impairment that substantially limits one or more of the major life activities of such an individual; 2) a record of such impairment; or 3) being regarded as having such impairment. If yes, what is the nature of your disability? __________________________________________________
Are you a Veteran? Yes No If yes, please check: Vietnam Era Other Disabled (1962-1975)
Sources of Applicants: How did you hear of the job for which you are applying? City Cable Listing City of Frederick Web Site Employee Referral (Please List Employee Name): ____________________ Job Announcement Posting Job Fair Job Service Office Newspaper (Please List Name of Newspaper): _______________________ Other Web Site (Please List Site): _________________________________ Other (Please List): ____________________________________________