Employment

Fill out the form below or download and complete the PDF version and submit it to the Village of West Salem offices.

The Village of West Salem considers all applications without regard to race, color, religion, creed, gender, natural origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Step 1 of 6

Personal / Professional References

List Three Personal / Professional References

Please list the names, addresses, and phone numbers of your three personal / professional references. DO NOT include relatives or past employers. Click the "+" sign to add another row.

Name

Address

Phone Number

Education Preparation And Training

High School Name

Date of Graduation

High School Location

City State

Training And Educational Preparation

Please list your previous employers, the dates you worked and the position you held

Name

Location

Dates Attended

Type of Training / Degree

Describe any experience, specialized training, apprenticeship, skills and extra-curricular activities that would qualify you for a position with the Village of West Salem.

Work Experience

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

Employer 1

Employer 1 - Phone Number

Employer 1 - Address

Street Address Address Line 2 City State ZIP Code

Employer 1 - Dates Employed (From / To)

Employer 1 - Job Title

Employer 1 - Supervisor

Employer 1 - Hour Rate / Salary

Employer 1 - Reason For Leaving

May we contact this employer?

Yes

Employer 1 - Work Performed

Employer 2

Employer 2 - Phone Number

Employer 2 - Address

Street Address Address Line 2 City State ZIP Code

Employer 2 - Dates Employed (From / To)

Employer 2 - Job Title

Employer 2 - Supervisor

Employer 2 - Hour Rate / Salary

Employer 2 - Reason For Leaving

May we contact this employer?

Yes

Employer 2 - Work Performed

Employer 3

Employer 3 - Phone Number

Employer 3 - Address

Street Address Address Line 2 City State ZIP Code

Employer 3 - Dates Employed (From / To)

Employer 3 - Job Title

Employer 3 - Supervisor

Employer 3 - Hour Rate / Salary

Employer 3 - Reason For Leaving

May we contact this employer?

Yes

Employer 3 - Work Performed

Employer 4

Employer 4 - Phone Number

Employer 4 - Address

Street Address Address Line 2 City State ZIP Code

Employer 4 - Dates Employed (From / To)

Employer 4 - Job Title

Employer 4 - Supervisor

Employer 4 - Hour Rate / Salary

Employer 4 - Reason For Leaving

May we contact this employer?

Yes

Employer 4 - Work Performed

Authorization For Release Of Information

(For official use only, not to be released to unauthorized persons)

I hereby authorize the Village of West Salem to obtain information and records, within one year of the date of this release, pertaining to me from any or all of the following sources:

Municipal, State, or Federal law enforcement agencies
Selective Service System
Any banking institution
Any place of business (for purposes of obtaining credit or employment data)
Credit rating bureaus or institutions
Any previous employer
Present employer
Any school, college, university, or other educational institution
Any law enforcement or jail officer

Exceptions to this blanket authorization:

Any medical information in the possession of any source named above until subsequent to a conditional offer of employment (per Americans With Disabilities Act).

Second Exception To The Above Blanket Statement

Third Exception To The Above Blanket Statement

This release is executed to authorize the Village of West Salem, as a prospective employer, to obtain the above information. It is understood that said information shall be used only in consideration of my employment and shall not be further disseminated for any purpose. (A criminal record does not constitute an automatic bar to employment and will be considered only if the circumstances of the conviction do not relate to the particular job in question).

Applicant's Name(Required)

Date(Required)

Applicant's Signature(Required)

Date(Required)

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Employment

Personal Data

Personal / Professional References

Education Preparation And Training

Work Experience

Additional Information

Authorization For Release Of Information

Review Form Before Submitting

Village of West Salem

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