City of Scottsboro
Voluntary Employment Inquiry

We are an equal opportunity employer. All information provided will be considered without regard to race, color, religion, creed, gender, age, marital status, political affiliation, national origin, or disibilities which do not affect the individuals ability to perform the essential functions of the position held or applied for with or without reasonable accommodation.

THE INFORMATION BELOW IS NEEDED TO COMPLETE THIS REVIEW.

NamePosition Sought
AddressDesired Wage
CityStateZip Code Telephone No.

TYPE OF EMPLOYMENT FOR WHICH APPLYING:
Check All That Apply

Seasonal Temporary Full Time Part Time
Hours or Shift Available

Days Available
EDUCATION:
Choose the number of years completed for each of the following

High School Undergraduate College Graduate College

Describe courses of major concentration:
Do you have a valid Driver's License? DL# State
Do you have a valid CDL License? Class
ADDITIONAL COMPETENCIES / JOB RELATED INFORMATION:
REFERENCES:
Name Name
Address Address
City State Zip Code City State Zip Code
Phone # Phone #
RELATIVES:
Certain relatives may not supervise relatives or report to the same supervisor.
EMPLOYMENT EXPERIENCE:
Start with your present or last employment, including military experience.
Employer

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving
Dates Employed
From
To



Hourly Rate/Salary
Starting
Final
Work Performed

Employer

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving
Dates Employed
From
To



Hourly Rate/Salary
Starting
Final
Work Performed

Employer

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving
Dates Employed
From
To



Hourly Rate/Salary
Starting
Final
Work Performed

Employer

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving
Dates Employed
From
To



Hourly Rate/Salary
Starting
Final
Work Performed

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment.
Yes No

Have you been convicted of a felony within the last 7 years?
Conviction will not necessarily disqualify an applicant from employment.
Yes No

I understand that employment is subject to drug and alcohol testing and certify that all information provided is true and complete to the best of my knowledge. I authorize the City of Scottsboro to investigate the information provided and understand that false or misleading information given in this employment inquiry or subsequent interview(s) may result in dis-selection or discharge.



Name:

Signature _____________________________

Date:

FEDERAL GOVERNMENT DEFINITIONS OF
AFFIRMATIVE ACTION CATEGORIES

White (not of Hispanic origin): any person having origins in any of the original peoples of Europe, North Africa or the Middle East.

Black (not of Hispanic origin): any person having origins in any of the Black racial groups of Africa.

Hispanic: any person of Mexican, Puerto Rican, Cuban, Central or South Americanor other Spanish culture or origin, regardless of race.

Asian or Pacific Islander: any person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This also includes, for example, India, China, Japan, Korea, the Phillippine Islands and Samoa.

American Indian or Alaskan Native: any person having origins in any of the original peoples of North America who maintains cultural identification through tribal affiliationor community recognition.

Disabled: a person who, (1) has a physical or mental impairment which substantially limits one or more of the person's major life activities; (2) has a record of such an impairment; or (3) is regarded as having such an impairment. A disability is substantially limiting if it is likely to cause the person difficulty in securing, retaining or advancing employment.

Disabled Veteran: any person entitled to disability compensation under laws administered by the Veterans Administration for a disability rated at 30 per centum or more or any person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.

Vietnam-era Veteran: any person who was on active duty with any branch of the United States military service during any portion of the Vietnam era and who, (1) served on active duty for a period of more than 180 days and was discharged or released with other than a dishonorable discharge or (2) was discharged or released from active duty for a service-connected disability. Federal regulations define the Vietnam era as the period between August 5, 1964 and May 7, 1975.

VOLUNTARY

To All Applicants:

The City of Scottsboro is an equal opportunity employer. We are committed to providing equal access and participation through our policies, processes, and actions to qualified applicants and employees. Please assist us by providing the information requested below.

Providing this information is voluntary and providing or refusing to provide it will not subject you to any adverse treatment. The information will only be used for equal opportunity record keeping and reporting. The information you provide is confidential and will not be available to participants in the selection process except in the case of disabled individuals, (1) supervisors and managers may be informed regarding any restrictions on work or job duties and necessary for reasonable accommodation(s) and (2) safety and health care personnel may bew informed, where appropriate, if the condition might require emergency treatment.

Check all of the following categories that are applicable to you. (Federal Government definitions of these categories are provided on the preceeding page.)

Female

White (not of Hispanic origin)

Hispanic

American Indian or Alaskan Native

Disabled Veteran
Male

Black (not of Hispanic origin)

Asian or Pacific Islander

Disabled

Vietnam-era Veteran


Name:

Signature _____________________________

Date: