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2. CITY OF MILLINGTON
   APPLICATION FOR EMPLOYMENT
4. We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of non-job-related medical condition or disability; or any other legally protected status.
6. OVERVIEW OF THE HIRING AND EMPLOYMENT PROCESS:
   This application is only one part of the hiring and employment process. Other parts may include an interview, an employment examination or test, and a demonstration of an ability to perform the essential functions of the job. If you need an accommodation in order to complete any part of the hiring and employment process, please call the following number: 901.873.5632.
8. Prior to completing this application be sure to read the JOB DESCRIPTION of the position for which you are applying. As you complete this application, please bear in mind the following:
   *We reserve the right to check all information for accuracy and completeness. *All application for employment are a matter of public record. *All required (*) fields must be completed.
10. POSITION APPLIED FOR*
11. DATE OF APPLICATION*
13. LAST NAME*
14. FIRST NAME*
15. MIDDLE NAME*
17. STREET*
18. CITY*
19. STATE*
20. ZIP*
22. CELL TELEPHONE*
23. ALTERNATE NUMBER*
24. EMAIL ADDRESS*
28. ARE YOU AT LEAST 18 YEARS OLD?*

    1. YES
    2. NO
29. ARE YOU AT LEAST 21 YEARS OLD?*

    1. YES
    2. NO
30. HAVE YOU EVER FILED AN APPLICATION WITH US BEFORE?*

    1. YES
    2. NO
31. IF YES, WHEN AND FOR WHAT POSITION?
33. HAVE YOU EVERY BEEN EMPLOYED BY US BEFORE?*

    1. YES
    2. NO
34. IF YES, WHEN AND IN WHICH POSITION?
35. ARE YOU CURRENTLY EMPLOYED?*

    1. YES
    2. NO
37. ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS?*

    Proof of citizenship or immigration status will be required upon employment.

    1. YES
    2. NO
38. ON WHAT DATE WOULD YOU BE AVAILABLE FOR WORK?*
39. ARE YOU CURRENTLY ON "LAY-OFF" STATUS AND SUBJECT TO RECALL?*

    1. YES
    2. NO
41. ARE YOU RELATED TO ANY MILLINGTON CITY OFFICIAL OR EMPLOYEE?*

    1. YES
    2. NO
42. IF YES, PLEASE STATE NAME AND RELATIONSHIP.
43. HAVE YOU EVER BEEN CONVICTED OF A CRIME?*

    Conviction will not necessarily disqualify an applicant from employment.

    1. YES
    2. NO
45. IF YES, PLEASE EXPLAIN.
46. DO YOU HAVE A VALID DRIVER'S LICENSE?*

    1. YES
    2. NO
50. ATTENTION - Notice to Applicant - IMPORTANT
    The information you provide in this application will determine if you meet the minimum qualifications for this job and whether you will be rated qualified for this position. You must provide SPECIFIC information regarding your education and experience relevant to both the "minimum qualification" and the "knowledge, skills and abilities" sections of the job posting. Specific information includes: job title; exact dates employed; detailed reason for leaving; name and current phone number for supervisor; detailed description of functions performed.
52. INFORMATION RELEASE*

    By checking the box below, I authorize the employers and / or educational institutions identified in this employment application to release ANY information they have concerning my employment or education, to the City of Millington.

    1. YES
54. EDUCATION
56. HIGH SCHOOL*
    Please provide school name, location, years completed, diploma / degree earned, honors received, and course of study.
58. UNDERGRADUATE COLLEGE / UNIVERSITY*
    Please provide school name, location, years completed, diploma / degree earned, honors received, and course of study.
60. GRADUATE / PROFESSIONAL*
    Please provide school name, location, years completed, diploma / degree earned, honors received, and course of study.
62. ACTIVITIES*
    List professional, trade, business or civic activities and offices held. You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status.
64. REFERENCES
    Give name, address, and telephone number of three references who are not related to you and are not previous employers.
66. NAME*
67. ADDRESS*
68. TELEPHONE NUMBER*
70. NAME*
71. ADDRESS*
72. TELEPHONE NUMBER*
74. NAME*
75. ADDRESS*
76. TELEPHONE NUMBER*
78. SPECIAL SKILLS AND QUALIFICATIONS*
    Summarize special job-related skills and qualifications acquired from employment or other experience.
80. ADDITIONAL INFORMATION
    State any additional information you feel may be helpful to us in considering your application.
84. EMPLOYMENT
    For employment history, please start with your present or most recent job. Include any job-related military service assignments and / or volunteer activities.
86. EMPLOYER*
87. ADDRESS*
88. JOB TITLE*
90. TELEPHONE NUMBER*
91. SUPERVISOR*
92. DATES EMPLOYED*
93. HOURLY RATE / SALARY*
95. WORK PERFORMED*
97. REASON FOR LEAVING*
99. EMPLOYER*
100. ADDRESS*
101. JOB TITLE*
103. TELEPHONE NUMBER*
104. SUPERVISOR*
105. DATES EMPLOYED*
106. HOURLY RATE / SALARY*
108. WORK PERFORMED*
110. REASON FOR LEAVING*
112. EMPLOYER*
113. ADDRESS*
114. JOB TITLE*
116. TELEPHONE NUMBER*
117. SUPERVISOR*
118. DATES EMPLOYED*
119. HOURLY RATE / SALARY*
121. WORK PERFORMED*
123. REASON FOR LEAVING*
125. EMPLOYER*
126. ADDRESS*
127. JOB TITLE*
129. TELEPHONE NUMBER*
130. SUPERVISOR*
131. DATES EMPLOYED*
132. HOURLY RATE / SALARY*
134. WORK PERFORMED*
136. REASON FOR LEAVING*
138. EMPLOYER
139. ADDRESS
140. JOB TITLE
142. TELEPHONE NUMBER
143. SUPERVISOR
144. DATES EMPLOYED
145. HOURLY RATE / SALARY
147. WORK PERFORMED
149. REASON FOR LEAVING
151. EMPLOYER
152. ADDRESS
153. JOB TITLE
155. TELEPHONE NUMBER
156. SUPERVISOR
157. DATES EMPLOYED
158. HOURLY RATE / SALARY
160. WORK PERFORMED
162. REASON FOR LEAVING
164. UPLOAD RESUME
168. DRUG AND / OR ALCOHOL TESTING
     I acknowledge that upon selection, I will schedule to undergo drug and / or alcohol testing. If tested for alcohol, the test will be a breath analysis test. The drug test will involve an analysis of a urine sample, which I will provide at a designated site. The purpose of the test will be to test for the presence of the following substances: amphetamines, marijuana, cocaine, opiates, PCP, alcohol, and / or any additional drugs listed in the Tennessee Drug Control Act. I acknowledge that the drug / alcohol screen test will be made available to the testing laboratory, medical review officer, the Personnel Director, or his / her designee. As an applicant, I am aware that a confirmed and verified positive drug / alcohol test result will rescind any conditional offer of employment. The City has a zero-tolerance policy on drug and alcohol abuse and depending on job classification may test randomly, post-accident and / or for probable suspicion.
170. APPLICANT'S STATEMENT
     I hereby certify that I have reviewed my application and all statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand and agree misstatements, falsified information and / or omissions of material facts may disqualify me and my application from further consideration for employment and may be considered justification for dismissal if discovered at a later date. Failure to provide any required information will result in my application not being considered. I waive any right of privilege, privacy, and / or confidentiality I may have in the information provided by references, or others whom I have indicated that may be contacted. NOTICE TO POLICE OFFICER APPLICANTS: All candidates for position of Police Officer must certify that he / she has NEVER been convicted of a crime of domestic violence in accordance with the Crime Bill, 1996, Lindberg Amendment, which states that "anyone convicted of a crime of domestic violence MAY NOT possess or own ANY KIND OF FIREARM."
172. HAVE YOU EVER BEEN CONVICTED OF A CRIME OF DOMESTIC VIOLENCE?*

     1. YES
     2. NO
174. ELECTRONIC SIGNATURE*
175. DATE*
177. The City of Millington would like to take this opportunity to thank you for your interest in the above referenced position and for your interest in serving the City's citizens in this selected capacity.
179. THE CITY OF MILLINGTON - PERSONNEL OFFICE
     7930 Nelson Road * Millington, Tennessee 38053 * Phone: 901-873-5632 * Fax: 901-873-5636
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