APPLICATION FOR EMPLOYMENT

City of Washington 405 Jefferson Street

Washington, MO 63090 Attn: Human Resources

We consider applications for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual orientation, citizenship status, genetic information or any other legally protected status.

(PLEASE PRINT) Position(s) Appli ed For Date of Application

How Diel You Learn About Us?

D Advertisement D Relative D Inquiry

D Employment Agency D Friend D Other

Last Name First Name Middle Name

Addr·ess Nu111ber Streel Ci1y Slate Zip Code

Telephone Number(s) Social Security Number (Voluntary)

I I

Best time to contact you at home is: AM

----PM

If you are under 18 years of age, can you provide required proof of your eligibility to work? D Yes D No

Have you ever fi led an application with us before? .. .... .... .. .. ... .. ... ... ... ...... ... ... ... ... ...... ... ... .. . D Yes D No

.... ... .......... ...... ... ...... ... ..... .......... ... .... .... .. ..... ................... .. If Yes, give date ______ _

Have you ever been employed with us before? ....... .. ....... .. .. .... ..................... ... ..................... D Yes

If Yes, give date ______ _

Do any of your friends or relatives, other than spouse, work here? .. ..... ............................ D Yes

Are you currently employed?........................................... .. ................. ..... .. .......... .. ....... ......... D Yes

May we contact your present employer?............... ........ ....................... .. ................... .. ..... .... D Yes

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Proof of citizenship or imm.igration status will be required upon employment. .. .. . . . .. . D Yes

Date available for work __ / __ / __ What is your desired salary range? _____ _

Are you available to work: (please indicate 1 2 3 shift)

D No

D No

D No

D No

D No

D Full-Time

D Part-Time

D Temporary

(please indicate Mornings Afternoon Evenings)

(please indicate dates available _!_!_ - _ !_ !_ )

Are you currently on "lay-off" status and subject to recall? ....... ... ... ... ..................... ........... D Yes

Can you travel if a job requires it? ............................................ .. .... .. .................................... D Yes

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

D No

D No

EDUCATION

Describe am s1wcializcd training, apprcnlil'l'ship . skills and l'\ lra-cu, ri u tlar ac ti\ ilil·s .

Ocscrihl' ~111\ job-related lr;1i11i11 1' I l'l'l' i\l·d i11 tliL· l 'nitl'd St;itL's 111ilitan .

EMPLOYMENT EXPERIENCE

Start with your present or last job. Inclu de any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

1.

2.

3.

4.

Employer

Address

Telephone Number (s)

Job Title Supervisor

Reason for Leaving

Employer

Address

Telephone Number(s)

Job Title Supervisor

Reason for Leaving

Employer

Address

Telephone Number(s)

Job Title Supervisor

Reason for Leaving

Employer

Address

Telephone Number(s)

Job Title Supervisor

Reason for Leaving

If you need additional space, please continue on a separate sheet of paper.

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:

ADDITIONAL INFORMATION

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

SPECIALIZED SKILLS ( CHECK SKILLS/EQUIPMENT OPERATED)

_Terminal _ Spreadsheet

_ Word Processing

_ Shorthand

Production/Mobile Machinery (list) Other (list)

PC/MAC

_Typewriter

WPM WPM

State anv additional i11for111atio11 you feel nun· be /,e/pfitl to U8 in co11sideri11f!, your applica I ion.

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HA VE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPL YING.

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation? __ YES __ NO

REFERENCES

(Name) Phone#

(Address)

2. _______________ _ _ ___ _ ( _ _ ) ----------(Name) Phone#

(Address)

3. _ ______ ___ _ _ ______ _ __ ( __ ) - - --------(Name) Phone #

(Address)

APPLICANT'S STATEMENT

I certify that answers given herein are tn1e and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant Date

FOR PERSONNEL DEPARTMENT llSF ONLY

Arrange Interview D Yes D No

Remarks ------------- - --- --- ----- ----- ----

INTERVI EWER DATE

Employed D Yes D No Date of Employment ____ __________ _

Hourly Rate/ Job Title _ _ _ _ ___ Salary _ __ _ Department _ _ _ ________ _

NAM E AND T ITLE DATE

This Application For Employment is sold for general use throughout the United Sta tes. Amsterda m Printing assum es no responsi bili ty for the use of said form or any questions which, when asked by the employer of the job applicant , may vio la te State and/or Federal Law.

q..\NT~ 4. IN O

Cl.SJ,., Rev 6/16 Re-order Form #23960 (23962 imprinted) ([)copy1ight 20 17 Amsterda m Print ing, Ams terdam , N.Y. 120 I 0 Toll Free 1 ·866A66· 1438 or on linc www.ams tcrdamforms.com Amsterdam·

CERTIFICATE OF APPLICANT

AUTHORIZATION FOR RELEASE OF INFORMATION

(READ CAREFULLY BEFORE SIGNING)

I, (Print Full Name) ____________ hereby certify that all statements made

on or in connection with this application are true and complete to the best of my knowledge

and belief. I understand and agree that any mis-statements or omission of material facts will

cause forfeiture on my part of all rights to employment with the City of Washington, Missouri.

I hereby authorize all law enforcement agencies, the Veteran Administration, U.S. Army, U.S.

Air Force, all military agencies, tax bureaus, credit bureaus, schools and universities, to furnish

the holder of this release with all and any available information regarding me in order that he

may determine my suitability for employment.

I authorize the holder of this release to make inquiry of my present and past employers

regarding my character, integrity, and reputation.

I authorize the release of any and all information regarding my employment, credit or any

other information, where personal or otherwise, that may or may not be in their records, and release said company of person from all liability for any damage whatsoever that my issue

from furnishing such information to the holder of this release.

A copy of this authorization will be considered as effective and valid as the original.

Driver's License# ----------Date of Birth ------------Are you related to any City of Washington employee or elected official? OYes D No

If yes, how are you related?----------------------

Signature of Applicant Date

DRIVER QUALIFICATIONS

Inspection of License Information

A. Driver's License Classification:

B. Endorsements:

C. Restriction Code

(enter, if this is the first review;

Check against existing license

To determine accuracy):

D. License Number:

E. Expiration Date:

F. Address:

Circle Those That Apply

AB CEFHM

BCHMNPTX

AGCDFIJLOUWZ

Number & Street

City State Zip Code

If any changes in the information above affect: classification, expiration date or restriction

code; and, have an impact on the driver's ability to meet City driving requirements, driver

should notify Human Resources of the change immediately and driver should not be allowed

to operate City vehicles.

Please submit on a separate sheet of paper and attach a statement detailing any moving traffic

convictions.

Signature of Employee---------------------

Type of Vehicle Qualified for: __________________ _

DRUG SCREENING AND CRIMINAL RECORD CHECK

Dear Applicant:

The City of Washington has adopted a Drug Screening and Criminal Record Check

Process for all new hires.

All Applicants with the City of Washington must sign below AND, if under the age

of 18 years, have a Parent/Guardian sign this form for parental consent for the drug

screening and criminal record check.

Only the applicants offered the positions will be required to submit to a drug

screening and criminal record check.

The position will be contingent upon receiving a negative result from the drug

screening and criminal record check. This consent also allows the release of the test

results to an authorized city representative for review.

Job Applicant Signature Date

Parent/Guardian Signature Date

*FORM MUST BE RETURNED WITH YOUR APPLICATION*

REQUEST FOR CRIMINAL RECORD CHECK

GENERAL INFORMATION APPLICANT'S LAST NAME FIRST MIDDLE JR/SR

MAIDEN L ALIAS LAST NAME FIRST MIDDLE JR/SR

ADDRESS STREET- P.O. BOX CITY STATE ZIP CODE

SEX DATE OF BIRTH SOCIAL SECURITY NUMBER RACE

D MALE (MM/DD/YYYY)

D BLACK D INDIAN D OTH ER

D FEMALE D WHITE D ASIAN

City of Washington Job Description

Maintenance Worker I (Laborer)

Status: Full-time-Seasonal

FLSA Status: Non-exempt

Department: Streets and Sanitation

Immediate Supervisor: Street Foreman and Street and Sanitation

Superintendent

General Purpose of Position

Completes maintenance of public facilities and works on capital projects as assigned

Major Duties and Responsibilities (Essential Functions)

Maintains City grounds and related properties Mows, weed-eats, and seeds grass

Performs raking and leaf pick-up

Mulches landscape

Picks up loose trash and empties trash receptacles

Trims trees and disposes of brush properly

Maintains City buildings and facilities Cleans, maintains and paints buildings

Cleans restrooms and repairs fixtures when needed

Checks for vandalism or broken items at facilities

Changes light bulbs, using heavy equipment when necessary

Performs other necessary cleaning or maintenance duties

Maintains City equipment Performs seasonal maintenance

Replaces equipment belts

Changes oil in equipment

Replaces equipment wheels and tires as needed

Performs other duties related to departmental activities Installs chain link fences

Serves as Refuse Collector when needed

Assists with concrete work and laying asphalt

Backfill sinkholes and other depressions

Repair and replace signs as needed

Bush hog drainage ditches and other areas

Complete general street maintenance activities

Run snow removal routes and assist with other snow removal activities

Keeps record of mileage/hours for vehicles and equipment

Maintains appropriate logs, including hours used, and maintenance reports for all equipment

Schedules and completes regular maintenance for equipment

Performs needed maintenance such as: oil changes, checks tires, lights, and general engine maintenance

Follows all work zone safety guidelines, wearing high visibility apparel, differentiate the worker from vehicles

using signs, drums

Completes construction projects as assigned Builds wood structures from frame-in to finishing carpentry

Performs metal work using welding techniques

Builds various constructs using concrete, including retaining walls, handicap ramps, etc.

Completes basic plumbing and electrical work

Marginal Duties and Responsibilities

Performs other duties as directed

Working Conditions

The work environment characteristics described here are representative of those an employee encounters while

performing the essential functions of this position. Reasonable accommodations may be made to enable individuals

with disabilities to perform the essential functions.

While performing the duties of this position, the employee is exposed more than two thirds of the time to conditions

such moving mechanical parts; fumes, airborne particles, cramped spaces; toxic or caustic chemicals, debris, and

outside weather conditions. The employee may also be exposed to high, precarious places, and vibration. The

employee may also be exposed to risk of electrical shock. The noise level in the work environment is usually loud.

This position may be called out 24 hours a day or rotate being on call, including weekends and holidays.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully

perform the essential functions of this position. Reasonable accommodations may be made to enable individuals

with disabilities to perform the essential functions.

While performing the duties of this position, the employee is regularly required to stand and walk, use hands to

finger, handle, hold or grip, or feel; reach with hands and arms and talk or hear. The employee is occasionally

required to sit, run, climb or balance and stoop, kneel, crouch, or crawl. Lifting, moving, pushing or pulling, raking

or shoveling up to 25 pounds does generally occur. Specific vision abilities required by this job include close vision,

color vision, depth perception, distance vision and ability to adjust focus.

Required Education and Experience

High school diploma or its equivalent. One to three months related experience and/or training; or equivalent

combination of education and experience. Must be able to read and write in English.

Preferred Education and Experience

Three to six months related experience and/or training; or equivalent combination of education and experience.

One year of general maintenance experience is desirable. An equivalent combination of education and experience

will be considered.

Licenses and Certifications

The person in this position must obtain a valid Class B Commercial Driver’s Missouri driver’s license within one

year of employment.

Knowledge, Skills and Abilities

Knowledge Knowledge of proper maintenance, repair and use of equipment assigned to area of responsibility such as

mowers, weed eaters, chain saws, loader, tandem axle dump truck.

Knowledge of city’s refuse collections routes and most efficient ways to run them

Knowledge of safety regulations and rules regarding compacting garbage trucks, traffic

Knowledge of layout of city streets

Knowledge of federal and state statutes concerning the work of the department

Knowledge of principles and processes for providing customer and personal services. This includes identifying

customer needs, meeting standards for service and customer satisfaction

Skills and Abilities Ability to speak effectively before groups of customers or employees of organization, effective communication

skills orally and in writing

Ability to write routine reports and correspondence

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and

procedure manuals

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages,

area, circumference, and volume

Ability to apply concepts of basic algebra and geometry

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram

form

Ability to deal with problems involving several concrete variables in standardized situations

Ability to prioritize daily work flow

Ability to meet specified or required deadlines

Ability to maintain accurate records

Ability to attend to duties reliably and predictably

Ability to follow departmental and City policies and procedures

Ability to read and interpret engineering grades and slopes

Knowledge of proper maintenance, repair and use of equipment assigned to area of responsibility such as

mowers, weed eaters, chain saws, loader, tandem axle dump truck. Ability to use various types of equipment,

including mowers, saws, weed eaters.

Ability to use various types of equipment, including weed eaters, mowers, saws

Ability to attend to safety of self and customers, identify hazardous situations

Supervision None

Signature and Approval

________________________________ __________________

Employee Date

________________________________ __________________

Department Director Date

________________________________ __________________

Human Resources Date

________________________________ __________________

City Administration Date

The above statements are intended to describe the general nature and level of work being performed by individuals

assigned to this job. They are not intended to be an exhaustive list of all essential functions, marginal functions,

responsibilities, duties, and skills required of personnel so classified in this position.