TOWN OF CHEYENNE WELLS EMPLOYEE SERVICES DIVISION APPLICATION FOR EMPLOYMENT Cheyenne Wells, Colorado 80810 Website: www.townofcheyennewells.com  151 South 1.P.O. Box 125  (719)767-5865 (719) 767-5069 Fax  THE TOWN OF CHEYENNE WELLSI IS AND EQUAL OPPORTUNITY EMPLOYER PLEASE COMPLETE ALLPORTIONS OF THIS APPLICATION  POSITION APPLYING FOR: PERSONAL INFORMATION FULLI NAME:  DATE:  REQUESTED SALARY  BIRTHDATE/OPTIONAL)  FULLI PHYSICAL AND MAILING ADDRESS:  HOME PH.  WORKI PH.  EMAIL  WHICH OF THE FOLLOWING WOULD YOU. ACCEPT ()FULLTIME O)PART-TIME O)TEMPORARY (SEASONAL  Alle employment offers are based upon applicant's abilityt toy provide satisfactory' "proof of identity" and legal rights  towork int the United States,  EDUCATIONALKNOWLEDGESKILLS  Type of School High School or GED Undergraduate Studies Other  School location dates attended  Graduation Degrees Major/Minor  ALL/ APPLICANTS APPLYING FORI POSITIONS WHICHI REQUIRE. ADVANCED EDUCATION DEGREES OR COURSEWORK, SPECIAL LICENSE, AND REGISTRATIONS! MAYI BE REQUIRED TO PROVIDE, APPROPRIATE SPECIAL SALISPROFESSIONAL LICENSESICERTIFCATIONSIVOLUNTEER WORK ORI INTERNSHIP  DOGUMENTATION.  INDICATE EXPERIENCE, TRAINING, OR SKILLS IN WORKING WITHI MICROSOFT OFFICE OR OTHER COMPUTER  SOPTWAREMARDWARE    LISTY YOUR MOST RECENTJOBS. YOUMAY: ADDI DOCUMENTS THAT RELATETO YOUR QUALIFICATIONS.  TITLE OF YOURI PRESENT ORI MOSTI RECENTI POSITION ATTENDED FROM-TO (MO. &YR.) MOST RECENT SALARY #OF EMPLOYEES YOU SUPERVISED SUPERVISOR'S! NAME SUPERVISORS PHONE! NUMBER  EMPLOYER  DUTIES PERFORMED  MAY WE CONTACT YOURI EMPLOYER FORI REFERENCE ()YES ()NO TITLE OF YOUR PRESENT ORI MOST RECENT POSITION ATTENDED FROM-TO (MO. &YR.) MOST RECENTSALARY #OF EMPLOYEES YOU SUPERVISED SUPERVISOR'SI NAME SUPERVISORS PHONE NUMBER  PHONE# DUTIESI PERFORMED  EMPLOYER  MAY WE CONTACT YOURI EMPLOYER FORI REFERENCE ()YES ()NO TITLE OF YOURI PRESENT ORI MOSTI RECENTI POSITION ATTENDED FROM-TO (MO. &YR.) MOST RECENT: SALARY #OF EMPLOYEES YOU SUPERVISED SUPERVISOR'S! NAME SUPERVISOR'S! PHONEI NUMBER  PHONE#  EMPLOYER  DUTIESI PERFORMED  MAY WE CONTACT YOURI EMPLOYERI FORI REFERENCE ()YES ()NO RELEVANT MEMBERSHIP INAPROFESSIONAL OR7 TECHINAL ASSOCIATION  PHONE#  Icertify that all statements made are true: and that any misstatements oft facts may be subject to disqualification or  dismissal. Date:  Signature: