The City of Andalusia
Employment Application

The City of Andalusia is an Equal Opportunity Employer.

The City of Andalusia will provide equal opportunity to all individuals and will employ applicants on the basis of their job-related qualifications and performance potential without regard to age, sex, religion, race, color, national origin, disability, political affiliation, or military status.

Please check that you agree before continuing.

By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.

Position of

General Information

First Name

Middle Name

Last Name

Street Address

City

State

Zip Code

Telephone Number

Driver's License Number

State

Expiration Date

Additional Information

Emergency Contact

In the event of an emergency, who should we notify?

Name

Telephone Number

Relationship

Address

Date of Birth

If applying for Police and/or Fire Department, date of birth required.

Month

Day

Year

Job Interest / Skills

Salary Desired

Type of employment requested

Full Time

Part Time

Temporary

Summer

Date you could begin working

Summarize any special skills or qualifications that apply to this job (Limit 130 Characters):

For Our Reference

Have you applied for a position here before?

Yes

If yes, when?

Have you ever been employed with the City of Andalusia?

Yes

If yes, please complete:

Department

Supervisor

From

Does the City of Andalusia employ any of your relatives?

Yes

If yes, please complete:

Name

Department

Relationship

Have you ever been known by any other name(s) which the City will require to verify the information contained in this application?

Yes

If yes, give name(s) and identify the related school, employer, etc.

Employment History

List your current or most recent employer first and indicate a continuous record of employment for the last ten years or from the time you left school.

Name of Employer

Address

Phone Number

May we contact this employer?

Yes

Supervisor and Title

Your title

Employed from

Starting Salary

Ending Salary

Work Performed (Limit 130 Characters)

Reason for leaving

Name of Employer

Address

Phone Number

May we contact this employer?

Yes

Supervisor and Title

Your title

Employed from

Starting Salary

Ending Salary

Work Performed (Limit 130 Characters)

Reason for leaving

Name of Employer

Address

Phone Number

May we contact this employer?

Yes

Supervisor and Title

Your title

Employed from

Starting Salary

Ending Salary

Work Performed (Limit 130 Characters)

Reason for leaving

Name of Employer

Address

Phone Number

May we contact this employer?

Yes

Supervisor and Title

Your title

Employed from

Starting Salary

Ending Salary

Work Performed (Limit 130 Characters)

Reason for leaving

Education

High School

Course of Study

Number of years attended

Grade average

Diploma

Graduate

GED

College or University

Course of Study

Number of years attended

Grade average

Degree, diploma, certificate and honors received

Other Education

Course of Study

Number of years attended

Grade average

Degree, diploma, certificate and honors received

Other Education

Course of Study

Number of years attended

Grade average

Degree, diploma, certificate and honors received

Specialized Training/Skills

List all current licenses and/or areas of certification (if not indicated above.)

Military Record

Have you ever served in the armed forces?

Yes

If yes, what branch?

From Month/Day/Year

To Month/Day/Year

Rank at discharge

Miscellaneous Information

Have you ever been convicted of a crime other than a minor traffic violation? A conviction record will not necessarily be a bar to employment.

Yes

If yes, please explain and describe in full detail (Limit 130 Characters):

Can you verify your legal rights to work in the U.S. by providing a birth certificate, proof of U.S. Citizenship, or by some other means?

Yes

Are you able to perform the job for which you are applying?

Yes

The City of Andalusia requires that all qualified applicants undergo a pre-employment physical examination and drug screen prior to employment. The City will pay the costs of such physical examinations provided the applicant begins work with and remains in the employ of the City for a minimum of 60 days. If the 60-day requirement is not met, the applicant shall be responsible for paying such examination charges. The City may deduct such charges from the employee's final pay.

References

Personal references, not former employers or relatives

Name

Occupation

Phone Number

Name

Occupation

Phone Number

Name

Occupation

Phone Number

Referrals

How were you referred to the Personnel Office?

Voluntary

State Employment Service

City Employee

Want Ad

Private Employment Agency

Other

Acknowledgement

I certify that the answers given by me in this application are correct to the best of my knowledge. I understand that any falsification of this application, whether intentional or accidental, is grounds for disqualification of employment consideration or dismissal from employment if I am hired. I authorize the City of Andalusia to contact any and all of the references and previous employers I have listed to obtain previous employment information or any other pertinent information that they may have. Further, I release the City of Andalusia and the above mentioned references from any and all liability for any damages that may result from information collected by the City of Andalusia.

Verification of eligibility to work in the United States will be required.

I further acknowledge and agree that no manager or representative of the City of Andalusia has any authority to enter into any employment contract. I understand and agree that, if I am employed, I will be an at-will employee during my probation period and the City of Andalusia may terminate my employment at any time during that probationary period.

I have read the above and I concur with the above as a condition of employment by the City of Andalusia, Alabama.

Email Address

Document Signers

- Applicant's Signature

​

General Information

Additional Information

Emergency Contact

Date of Birth

Job Interest / Skills

For Our Reference

Employment History

Education

Specialized Training/Skills

Military Record

Miscellaneous Information

References

Personal references, not former employers or relatives

Referrals

Acknowledgement