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511 Sixth Avenue Belle Fourche, SD 57717 Phone: (605) 892-2494 Fax: (605) 892-2784

City of Belle Fourche Equal Opportunity Employer

►What Position are you applying for?

Employment Application – Please print clearly!

1. All job applicants must complete the following application form before being employed. Please print clearly in ink or type all answers except signature. Photocopies are acceptable. You are welcome to attach a resume, apply certifications and letters of recommendation.

2. Equal Opportunity Employer – It is the policy of the City of Belle Fourche to affirmatively recruit, hire, train and promote the most qualified persons into all job levels without regard to race, color, religion, national origin, sex, or disability, and to recruit for disabled veterans, and veterans of the Vietnam Era.

3. Americans with Disabilities Act Compliance: The City of Belle Fourche fully subscribes to the provisions of the Americans with Disabilities Act and will attempt in its employment process to make any reasonable accommodations necessary to assist qualified persons with disabilities. If you need assistance, please ask and we will help you.

4. If you wish to claim veterans’ preference, please attach DD Form 214 or other suitable evidence of service during qualifying periods.

5. If you are the spouse of a veteran or a disabled veteran and would like to claim the veteran’s preference, please mark this box.

6. Successful applicants are subject to our drug/alcohol screening policy. The City conducts urine drug screening for pre-employment and at prescribed times for safety-sensitive positions. Your offer of employment will be withdrawn if you refuse testing or test positive (evidence of drug usage). The City complies with the Drug-Free Workplace Act of 1988 in our employment practices and policies.

7. Background checks are conducted for all employees 18 years of age or older, or under 18 who have been convicted of a crime in adult court. One or more convictions will not necessarily disqualify you from employment. The decision will be based on a number of factors such as the duties of the job for which you are being considered, the seriousness of the offense of which you were convicted, your age at time of conviction, rehabilitation efforts, how recent the conviction was, etc. Failure to disclose convictions may result in disqualification.

8. Please be complete. All information is subject to verification.

Applicant Information

Full Name:

Date:

Last First M.I.

Address:

Street Address Apartment/Unit #

City State ZIP Code

Phone: Cell:

Date Available: Desired Salary: $

Are you a citizen of the United States? YES

NO

If no, are you authorized to work in the U.S.? YES

NO

Have you ever worked for this company? YES

NO

If yes, when?

Work Authorization

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Education/Training

Do you have a high school diploma or GED? YES

NO

Circle highest year of education completed: 8 9 10 11 12 13 14 15 16 17 18 19 20

Please list high school, college or vocational institution attended; first to last:

Name Address: Major Degree

Received:

Name Address: Major Degree

Received:

Name Address: Major Degree

Received:

List other training that may be applicable to your skills and abilities as a job applicant:

(Other training) List equipment and/or machinery you are trained and qualified to operate:

(Other equipment) List any special skills you have that may be applicable to your consideration as a job applicant:

(Special skills)

References (Other than relatives and former employees)

Please list three professional references.

Full Name: Relationship:

Company: Phone:

Address:

Full Name: Relationship:

Company: Phone:

Address:

Full Name: Relationship:

Company: Phone:

Address:

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Previous Employment

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

Duties performed Duties performed

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES

NO

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

Duties performed Duties performed

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES

NO

Company: Phone:

Address: Supervisor:

Job Title: Starting Salary: $ Ending Salary: $

Responsibilities:

Duties performed Duties performed

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES

NO

Have you ever been dismissed or asked to resign from any position?

YES

NO

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Military Service

Branch: From: To:

Rank at Discharge: Type of Discharge:

If other than honorable, explain Are you now a member of the National Guard or Reserves?

YES

NO

If offered employment with the City of Belle Fourche, I will / will not be willing to sign an authorization for release of my medical information for the Human Resources Dept. as needed for performance of my duties. Are you able to perform the essential job functions with or without a reasonable accommodation for the position for which you applied?

YES

NO

If accommodation is requested, what type of accommodation is needed?

Disclaimer and Signature

Can you, after employment, submit verification of your legal right to work in the United States? YES

NO

I certify that my answers are true and complete to the best of my knowledge. I understand that if I am employed, any false or misleading information in my application or interview may be grounds for dismissal. I authorize investigation of all statements contained in this application. I also grant permission to contact all references listed above, (unless noted otherwise), and authorize them to release all information concerning my previous employment and any other pertinent information these references may have, personal or otherwise. I release all parties from all liability for any damage that may result from furnishing this information to you.

I understand that nothing in this application is intended to imply or create any employment relationship or contract for employment. I further understand that, if hired, my employment is at-will and can be terminated at any time, with or without notice, for any reason. I also understand that, while personnel policies, programs, and procedures may change from time to time, such at-will status is not subject to change without a written agreement signed by an authorized representative of the City of Belle Fourche.

Signature: Date:

Medical Release

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Equal Employment Opportunity Form Optional Applicant Information

Full Name:

Last First M.I.

Address:

Street Address Apt/Unit #

City State ZIP Code

Home Phone with area code: Date of application:

Position Applied for:

Voluntary Information

This information is being requested in accordance with federal regulations. The information is voluntary and will not be used when considering you for employment with our company. This page is not distributed with your application when under consideration.

Racial or Ethnic Group

American Indian/Alaskan Asian/Pacific Islander Black/African American

Hispanic/Latino White/Caucasian Other

Gender

Female Male

Military Service

Pre-Vietnam Era Vietnam Era

Post-Vietnam Era Disabled Veteran

How did you hear about this position?

Newspaper Company Employee Professional Publication

Job Fair Placement Office Web Site

Other

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Substance abuse has an adverse impact on an employee’s work, personal and family lives, as well as on the ability of the City of Belle Fourche to provide the highest quality of services. Alcohol and drugs can cause poor performance, decrease productivity, and create safety hazards. Consequently, the City of Belle Fourche is committed to establishing and maintaining an alcohol and drug free workplace. Please answer the following three (3) questions.

1.) Are you presently using any form of illegal drug? Yes □ No □

2.) Have you used any illegal drug in the past 6 months? Yes □ No □

3.) Would you be willing to submit to a drug test? Yes □ No □

I understand and will abide by the City of Belle Fourche Drug Abuse Policy.

Name (please print)

Signed Date / /

Witness

CITY OF BELLE FOURCHE ALCOHOL AND DRUG-FREE WORKPLACE

POLICY

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DISCLOSURE AUTHORIZATION AND CONSENT FORM THIS FORM IS FOR PERMANENT RETENTION IN PERSONNEL FILE

PLEASE READ CAREFULLY

We truly welcome your application with City of Belle Fourche. You are applying for a position whose acceptance will place you in a category of recognized professionals. In pursuit of that excellence we require, as a condition of employment, that all applicants consent to and authorize a pre-employment and/or continued employment verification of their background, including information submitted on their application or resume. The City of Belle Fourche does not use this authorization to obtain your credit report. If a credit report is needed for the position that you are applying for, you will be contacted by the Human Resources office.

DISCLOSURE

This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in Section 604 (b) to the applicant that a social security number trace, motor vehicle verification, education, previous employment, and a criminal background verification may be obtained for the purpose of this employment application. In addition, investigative consumer reports gathered from personal interviews with former employers and other past or current associates of mine to gather information regarding my work performance, character, general reputation and personal characteristics may be obtained for the purpose of this employment application. By the signature below, the Applicant acknowledges that AccuSource, Inc. has made this disclosure. CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.

As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.

A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

APPLICANT AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION

This release and authorization acknowledges that City of Belle Fourche may now, or any time while I am employed/training, conduct a verification of my education, previous employment/work history, contact personal references, motor vehicle records, conduct drug testing and to receive any criminal history information pertaining to me which may be in the files of any Federal, State, or Local criminal justice agency, and to verify any other information deemed necessary to fulfill the job requirements. The results of this verification process will be used to determine employment/training eligibility under City of Belle Fourche employment/training policies.

CITY OF BELLE FOURCHE FCRA AUTHORIZATION FORM

APPLICATION FOR VOLUNTEER OR EMPLOYMENT

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In the event that information from the report is utilized in whole or in part in making an adverse action decision with regard to your potential employment/training, before making the adverse decision, we will provide you with a copy of the consumer report and a description in writing of your rights under the law any time a consumer is required to receive a summary of rights required under section 609. I authorize AccuSource, Inc. at 1240 E. Ontario Avenue, Suite 102-140, Corona, California 92881, 951-734-8882, customerservice@accusource-online.com, www.accusource-online.com, and any of its agents, to disclose orally and in writing the results of this verification process to the designated authorized representative City of Belle Fourche. Contact AccuSource, Inc., if you want to receive a copy of our Information Security Policy.

I have read and understand this disclosure, and I authorize the background verification. I authorize persons, schools, current and former employers, and other organizations and Agencies to provide AccuSource, Inc. with all information that may be requested. I agree that any copy of this document is as valid as the original. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment/training was denied based on information obtained by my prospective employer/training program and to receive a disclosure of the public record information and of the nature and scope of the investigative report. Applicant Signature:

Please complete the following questions.

PLEASE PRINT CLEARLY

CONFIDENTIAL INFORMATION FOR POSITIVE IDENTIFICATION PURPOSES ONLY Applicant Last Name First Name Middle Name List Other Names Used (MAIDEN NAME) Date of Birth (For Identification only) Social Security Number Driver’s License Number State Driver’s License Issued Last Name on Driver’s License Current Address City/State/Zip Dates Previous Address City/State/Zip Dates Previous Address City/State/Zip Dates

RELEASE MUST BE SIGNED

Applicant’s Signature Today’s Date E-mail address

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TO WHOM IT MAY CONCERN: I have applied for a position with the City of Belle Fourche. I authorize investigation of all information as may be necessary in arriving at an employment decision. I authorize the City of Belle Fourche, or its representatives, to contact any professional reference, former employer, education-provider, or other collateral source for job-related information and for the purpose of verifying any of the information I have provided to the City of Belle Fourche and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me. I herby release the organizations, their agents and/or employees and individuals supplying such information from any and all liability or damages whatsoever for providing the information requested. A photocopy or fax of this authorization shall be as valid as the original. This authorization expires 60 days from the date of my signature.

Signature

Name (please print)

Social Security Number

Date

AUTHORIZATION OF RELEASE OF INFORMATION

For Reference Checks

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I acknowledge that my child has applied for employment with the City of Belle Fourche. I understand and agree that my child will need to comply with City of Belle Fourche policy regarding alcohol and controlled substance use and/or abuse. I further understand that failure to comply with this policy may result in dismissal from employment. I understand that I am responsible for paying for evaluation by DOT certified Substance Abuse Professional, return to duty, follow up testing and for any required rehabilitation under this policy. I also understand that City of Belle Fourche will pay for post-accident, random and reasonable suspicion testing. I further understand that in connection with my child’s application for employment, the City of Belle Fourche, may obtain consumer reports as part of the process of considering their candidacy as an employee. Such reports may include, but are not limited to, criminal background checks, credit reports, employment and education verifications, social security verification, and drug screening. I acknowledge that in the normal performance of my child’s duties that accidents may happen even though safety measures are taken. By my signature below, I authorize the City of Belle Fourche or their representative to proceed with any emergency care that my child may need. I understand that the City will notify me as soon as possible of any such accident. Employee Name (printed): Employee Signature: Date: Parent/Guardian Name (printed): Parent/Guardian Signature: Date:

PARENTAL CONSENT FOR EMPLOYEES WHICH ARE UNDER AGE 18

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