TOWNOFNEWINGTON

205 Nimble Hill Road,Newington,NH 03801

APPLICATIONFOREMPLOYMENT

EmployeesoftheTownandapplicantsforemploymentshallbeaffordedequalopportunityinallaspectsof employmentwithoutregardtorace,color,religion,sex,nationalorigin,age, maritalstatus,ordisability.

TheTownofNewingtonwillmakereasonableeffortintheemploymentprocesstoaccommodatepersonswith disabilities.Ifyouwillrequirespecialaccommodationsduringtheapplication/hiringprocess,pleasenotifyHuman Resourcesprior to thedeadlinefor submitting an application for thisposition.

Applicationsremain active for a maximumof one (1) year.

(PleasePrintorType)

BIOGRAPHICALDATA
FullName: / SocialSecurity#:
StreetAddress: / HomePhone:()
City:State:Zip: / WorkPhone:()
Haveyoueverbeenemployedwithusbefore?No[]
Yes[]Ifyes,providedetailsbelow.
TitleofPositionheld: / TerminationDate:
Reasonsforleaving:
ListanyrelativecurrentlyworkingfortheTownofNewington:
Name / Department / Relationship
DoyouhavealegalrighttoacceptemploymentintheUnitedStates?Yes []No []
Ifyouareunder18yearsofage,canyouproviderequiredproofofyoureligibilitytowork?
Yes []No []
EDUCATION
DidyoureceiveahighschooldiplomaorGED? / Yes[ / ] / No[]
Circlehighestgradecompleted:7 891011 12 / College: / 12 / 3 / 456
School (name, city, state) / Dates / Degree / Course of Study
HighSchool
Undergraduate
College/University
Graduate/Professional
College/University
OtherEducation(i.e., Technical,Business)

ANEQUALOPPORTUNITYEMPLOYER

EMPLOYMENTHISTORY(List most recentemployer first)
Company: / YourTitle:
StreetAddress: / EmployedFrom(date):
City,State,Zip: / EmployedTo(date):
Maywecontactyourpresentemployer?
Yes[]
No[] / CurrentSalaryorRateofPay:
Starting:Per Ending:Per
Responsibilities:
Supervisor'sname: / PhoneNo.:
Reasonsforleaving:
Company: / YourTitle:
StreetAddress: / EmployedFrom:
City,State,Zip: / EmployedTo:
SalaryorRateofPay: / Starting: / Ending:
Responsibilities:
Supervisor'sname: / PhoneNo.:
Reasonsforleaving:
Company: / YourTitle:
StreetAddress: / EmployedFrom:
City,State,Zip: / EmployedTo:
SalaryorRateofPay: / Starting: / Ending:
Responsibilities:
Supervisor'sname: / PhoneNo.:
Reasonsforleaving:
CRIMINALHISTORY
Haveyoueverbeenconvictedofacrimethathasnotbeenexpungedbyacourt? Yes [ ]No [ ]IfYes,explainfully(Convictionwill notautomatically disqualify you from employment.Each situation is considered on its individual merit.Lack of explanation orfailure to complete this section may bea basis forrejection of this application):
REFERENCES
Listthree(3)personalReferenceswhoarenotformeremployersorrelatedtoyou:
NameOccupation / Address / Phone / Relationship

CERTIFICATIONANDAGREEMENT

PLEASEREADCAREFULLYBEFORESIGNING

Insubmittingthisapplicationforconsiderationandasindicatedbymysignaturebelow,Iherebycertifythatallresponses providedhereinandthroughouttheapplicationprocessaretrueandcompletetothebestofmyknowledge.Iauthorizethe TownofNewingtonand/oritsauthorizedagent(s)toinvestigatemypersonalandemploymenthistory,andfinancialand creditrecord.Ifurtherauthorizeinvestigationofallstatementscontainedinthisapplicationforemploymentasmaybe deemednecessaryinarrivingatanemploymentdecision.Iunderstandthatshouldaninvestigationatanytimediscloseany misrepresentations and/or falsificationsas stated herein,upon any other employment-related form or made duringan interview(s),myapplicationwillberejectedandshouldIbecomeoralreadybeemployedwiththeTownofNewington,my employmentmay beterminated.

IunderstandthatifIamemployedbytheTownofNewington,Iamrequiredtobecomefamiliarwithandabidebyallrules andregulationsoftheTownofNewingtonasestablishedandamendedfromtimetotime.Iunderstandandacknowledge that,unlessotherwisedefinedbyapplicablelaw,anyemploymentrelationshipestablishedwiththeTownofNewingtonisof an“atwill”nature,whichmeansthattheemployeemayresignatanytimeandtheTownofNewingtonmaydischargethe employeeatanytimewithorwithoutcause.Ifurtherunderstandthatthis“atwill”employmentrelationshipmaynotbe changedbywritteninstrumentorbyconductunlesssuchchangeisspecificallyacknowledged,inwriting,byanauthorized representativeoftheTownofNewington.

Ireleaseanyindividual,includingrecordcustodians,fromanyandallliabilityfordamagesofwhateverkindornaturethat may,atanytime,happentomeasaresultofcompliance,oranyattemptstocomplywiththisauthorization.

(Applicant’sSignature)(Date)

The Town ofNewingtonis an Equal OpportunityEmployer