All Required fields are marked with *. Please indicate each job title for which you are applying* Personal information Name First* M.I. Last* Address line 1*   Address line 2   City* ST * Zip code * Telephone Home Work E-Mail Cellphone   Type of employment desired *  temporary   full time   part time   Do you meet the stated age requirement (if any)?   yes no If hired, can you verify your legal right to work in the United States?* yes no Can you perform the essential job functions for this position?* yes   no If no, please explain on a separate page how we can accommodate you. Have you ever been convicted of a violation of the law, excluding minor traffic violations?* yes   no If yes, please explain fully on a separate page. Convictions do not automatically disqualify you. Describe any job-related skills, knowledge, special training, certificates, licensing, machines or equipment you can operate or possess as they support your application for this position. Education and Training Please indicate the number of years completed* High School 1   2   3   4     College 1   2   3   4     Graduate 1   2   3   4   High school name and location Did you graduate?   Yes   No GED   College or trade school name and location Attended (mm/yy) from   to Did you graduate?   Yes   No Name of certificate or degree Graduate School name and location Attended (mm/yy) from   to Did you graduate?   Yes   No Name of certificate or degree Employment Experience Begin with your present or most recent employment. List both paid and related volunteer work. May we contact your present employer? Yes No Most recent (or current) employer name and address* From   to Hours per week Salary per Hour Month Employer's telephone number Job title and duties Supervisor's name Reason for leaving Second most recent employer name and address From   to Hours per week Salary per Hour Month Employer's telephone number Job title and duties Supervisor's name Reason for leaving Third most recent employer name and address From   to Hours per week Salary per Hour Month Employer's telephone number Job title and duties Supervisor's name Reason for leaving Applicant's Certification I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this application in any detail is grounds for disqualification or for dismissal of employment. I agree to conform to the rules and regulations of my employer. I consent to and authorize the City of Albany to ask for information concerning me. I further understand that I may be fingerprinted, required to submit to a complete medical examination, to a psychological test and to furnish such proof of age and education as may be requested, or otherwise investigated prior to appointment. I release all parties and persons connected with any requests for information from all claims, liabilities and damages for whatever reason arising out of furnishing this information. Do you so certify? *  yes   no Equal Employment Opportunity Questionnaire The City of Albany is asking all applicants to complete this form in order to comply with United States government equal employment opportunity requirements. Data collected will be used for statistical purposes and to measure effectiveness of recruitment efforts. This information which you provide voluntarily will be detached from your application and will be kept separate and confidential. The City of Albany is an equal opportunity employer. Sex male   female Age 40 or above? yes     no Ethnic origin (please check only one) White - not of Hispanic origin (all persons having origins in Europe, Northern Africa or the Middle East, includes Spain and Portugal). Black - not of Hispanic origin (all persons having origins in any black racial group in Africa). Hispanic - all persons of Mexican, Puerto Rican, Cuban, Central or Southern American or any Hispanic culture or origin regardless or race. Asian or Pacific Islander - all persons having origins in any of the original peoples of the far east, south east asia, the indian sub-continent or the pacific islands (includes china, japan, philippine islands, samoa, et cetera). American Indian or Alaskan Native - all persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.   How did you learn of this recruitment? (please check only one and provide name below) Current employee Newspaper or other publication Community organization City of Albany web site Other Internet site Name of source

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