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Employment Application Instructions
Employment Application Instructions (PDF)
Last Name
First Name
Middle Name
Address
City
State
Zip Code
Phone
Email
Position Desired
Date Available
Date Available
Desired Salary
Please select types of work desired:
1. Full-time
2. Part-time
3. Temporary
1. Days
2. Evenings
3. Nights
Have you ever been employed with the City of Keene?
1. Yes
2. No
Are you related by blood or marriage to anyone working in this organization, including Council members?
1. Yes
2. No
Whom are you related to, and what position do they hold?
Are you over 18 years of age?
1. Yes
2. No
Have you been fired or asked to resign from a job within the past five years?
1. Yes
2. No
Have you served in the military?
1. Yes
2. No
Type of Discharge
If other than honorable, please explain.
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Education

Did you graduate from high school?
1. Yes
2. No
What school did you graduate from?
Do you have your General Educational Development (GED) diploma?
1. Yes
2. No
What is the highest level of school you completed?
College/University Education
College/University
Major
Minor
Degree Earned
Date Earned
Date Earned
College/University
Major
Minor
Degree Earned
Date Earned
Date Earned
College/University
Major
Minor
Degree Earned
Date Earned
Date Earned
Vocational/Trade School Education
Vocational/Trade School
Area of Study
Certificate Received
Date Earned
Date Earned
Expiration Date
Expiration Date
Vocational/Trade School
Area of Study
Certificate Received
Date Earned
Date Earned
Expiration Date
Expiration Date
Vocational/Trade School
Area of Study
Certificate Received
Date Earned
Date Earned
Expiration Date
Expiration Date
Licenses & Certifications
License/Certification Held
Expiration Date
Expiration Date
License/Certification Held
Expiration Date
Expiration Date
License/Certification Held
Expiration Date
Expiration Date
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Employment History

Skills & References

Special Qualifications & Skills
Please list any specialized skills, technical knowledge, or training you possess that may be applicable to the position you are applying for. Include any software, machinery, or equipment you are able to use.
References
Full Name
Relationship
Phone Number
Full Name
Relationship
Phone Number
Full Name
Relationship
Phone Number
Reference Check Authorization
I authorize any person or organization listed in this application and/or whose name I have given as a character reference and/or by whom I have been previously employed and/or any educational institution I have listed on this application to furnish any information they may have concerning me to the City of Keene. I understand that the information provided by me may be used for the purpose of determining eligibility. My previous employers may be contacted, unless otherwise noted by me on this application or in writing. I hereby release, indemnify, and hold harmless any governmental entity, employer, and person furnishing or receiving records and information about me.

By typing your name into this section, you are signing this agreement electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this agreement. You consent to be legally bound by this agreement’s terms and conditions. You further agree that your use of a keypad, mouse, or another device to select an item, button, icon, or similar act/action is acceptance and agreement as if actually signed by you in writing.
Signature of Applicant
Date
Date
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Driving & Background

Driving Classification & Record
The City of Keene requires that all employees have a valid driver license and must maintain a satisfactory driving record.
Date of Birth
Date of Birth
Driver License Number
Issuing State
License Class
1. A
2. B
3. C
Do you have a Commercial Driver License (CDL)?
1. Yes
2. No
Please list the class and endorsements that you carry.
Background Information
To assist the City of Keene in obtaining and evaluating your background, please provide the following information.
Have you been issued a citation or ticket for any motor vehicle violations within the past three years?
1. Yes
2. No
Violation
Date Received
Date Received
Violation
Date Received
Date Received
Violation
Date Received
Date Received
Have you ever been convicted, plead guilty, pled no contest, placed on deferred adjudication, or community supervision for a felony or misdemeanor (class A, B, or C) in a civilian court or military court?
1. Yes
2. No
Charge
City/County Location
Date Received
Date Received
Charge
City/County Location
Date Received
Date Received
Charge
City/County Location
Date Received
Date Received
Applicant's Signature
Date
Date
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Equal Employment Opportunity

Equal Employment Opportunity (EEO) Information Survey
Thank you for completing this application form and for your interest in working with the City of Keene. We base all hiring decisions on merit alone. The City of Keene is an equal opportunity employer. In accordance with the Civil Rights Acts of 1964 and 1991, as amended, the Age Discrimination in Employment Act, and the Americans with Disabilities Act, the City of Keene shall not discriminate against any employee or applicant for employment because of age, sex, national origin, religion, race, disability, or any other reason prohibited under Federal, State, or local laws. Although this information is optional, we would appreciate your supplying the information requested.

Please note: this information will be used for statistical reporting purposes only. It will be separated from your application and will not be used in any way in evaluating your qualifications for employment nor will it become a part of your file if you are not hired.
Typing your name into this section, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a keypad, mouse or another device to select an item, button, icon or similar act/action is acceptance and agreement as if actually signed by you in writing.
Signature
Date
Date

Leave This Blank:

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

This field is not part of the form submission.
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