2. 

   
   

   Application for Employment

   
   

   Equal Opportunity Employer Discrimination in employment because of race, religion, creed, color, national origin, ancestry, disability, age, sex, or liability for service in Armed Forces of the United States is prohibited by city policy.  In addition, City employment policy requires compliance with state and local fair employment practice laws and regulations.  The City of Defiance is an equal opportunity employer.

6. First Name
7. Middle Name
8. Last Name
10. Address
12. City
13. State
14. Zip Code
16. Phone Number
17. Email Address

21. General Information

23. Position Applying For:
25. Have you ever worked for the City of Defiance?

    1. Yes
    2. No
26. If yes, reason for leaving and year
28. Do any of your relatives or friends work here?

    1. Yes
    2. No
29. If yes, please list
31. Are you currently employed?

    1. Yes
    2. No
32. Date Available for Work
    Date Available for Work
34. What is your desired salary range?

38. Education

40. School
    -- Select One --High SchoolUndergraduateGraduateOther
41. School Name & Course of Study
42. Did You Graduate?

    1. Yes
    2. No
44. School
    -- Select One --High SchoolUndergraduateGraduateOther
45. School Name & Course of Study
46. Did You Graduate?

    1. Yes
    2. No
48. School
    -- Select One --High SchoolUndergraduateGraduateOther
49. School Name & Course of Study
50. Did You Graduate?

    1. Yes
    2. No
52. School
    -- Select One --High SchoolUndergraduateGraduateOther
53. School Name & Course of Study
54. Did You Graduate?

    1. Yes
    2. No

58. Employment History

60. Employer #1

62. Employer
63. Employer Phone Number
65. Job Title
66. Salary
68. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
69. Reason for Leaving
71. Job Duties

73. Employer #2

75. Employer
76. Employer Phone Number
78. Job Title
79. Salary
81. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
82. Reason for Leaving
84. Job Duties

86. Employer #3

88. Employer
89. Employer Phone Number
91. Job Title
92. Salary
94. Dates Employed
    Dates Employed Start Date

    —

    Dates Employed End Date
95. Reason for Leaving
97. Job Duties

99. References

    In the areas below, please provide 3 professional references.

101. Reference #1 Name
102. Reference #1 Phone Number
104. Address
106. City
107. State
108. Zip Code
110. Reference #2 Name
111. Reference #2 Phone Number
113. Address
115. City
116. State
117. Zip Code
119. Reference #3 Name
120. Reference #3 Phone Number
122. Address
124. City
125. State
126. Zip Code

130. Additional Information

132. Describe any specialized training, apprenticeship, skills, computer skills, or additional information that you feel may be helpful to us in considering your application:
134. List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:
136. Send to: llambert@cityofdefiance.com
Leave This Blank:


138. 1. Receive an email copy of this form.
139. Email address

     This field is not part of the form submission.

140. Submit Submit and Print

* indicates a required field