City ofLittlefield P.O. Box 1267 301 XIT Drive Littlefield, Texas 79339 Phone 806)385-9202.204 Fax (806)385-0014  Instructions: Iti is important that you answer all questions on this application fully and accurately. Failure to do sO may delay its consideration and could mean loss of employment opportunities. If an item does not apply to you, or ifthere is no information to be given, please write in the letter  "NA": for not applicable. DATE: ADDRESS: TELEPHONE:  NAME:  (Law Enforcement) TCLEOSE PID#:  List names ofa all relatives already employed by the City ofLittlefield:  Have you worked for the City ofLittlefield before under this or any other name?  No When:  Yes  What was the other name? What Position:  Position applying for now:  Types ofwork you will accept: Regular  Full Time  Temporary  Part time Weekend  Shift work  Day time  Night time  Minimum salary requirement per month:  Are you eligible to work in the United States and verify I-9 requirements?  Driver License: # Regular Class C: Passenger fyes, explain:  State:  CDL License: A B C HAZMAT YES  Exempted A  orl B Tank  Endorsements: Double/Triple Trailer  Have you ever hady your driver license suspended? NO  Note: A prior conviction will. NOT automatically disqualify an applicant for employment and will  be considered only as it relates to the job appliedfor.    Did you graduate from high school or receive a G.E.D. certificate? No  Yes  Name ofSchool  City State Yes Degree Earned:  Last grade completed  Did you graduate from college? No Number of years completed:  Please, list all trade schools, military schooling, business colleges, police training, skills, etc. you  have had:  EMPLOYMENT RECORD: Starting with your present or last job, and including your military service assignments, list all jobs you. have had since leaving school. This section must be  completed despite the possible submission ofa resume. May we contact your present employer? No  Yes Your position Telephone Name of Supervisor  Employer Address  Dates employed: From Describe work performed  To  Reason for leaving:  Employer Address  Your position Telephone Name of Supervisor  Dates employed: From Describe work performed  To  Reason for leaving:    Employer Address  Your position Telephone Name of Supervisor  Dates employed: From Describe work performed  To  Reason for leaving:  Employer Address  Your position Telephone Name of Supervisor  Dates employed: From Describe work performed  To  Reason for leaving:  READ CAREFULLY BEFORE SIGNING  Ihereby certify that the statements made and answers given by me to the foregoing questions are true and correct and that there are no omissions of any kind whatsoever. Iagree that any evasion, untruthful statement, answer, or omission shall be sufficient cause for discharge at any time. Iagree tos submit to physical examination including drug screen, whenever requested by City ofLittlefield, by doctor, or doctors designated by the City, either prior to or during the course of employment, subject to the requirements of specific accommodations. I hereby release all doctors, medical personnel, and elected officials from all liability claims and damages in connection to furnishing any information to the City of Littlefield. Ihereby request and authorize the companies or persons shown under "Employment Record" or other interest parties, not necessarily named in the foregoing application, to furnish the City of Littlefield any information regarding my employment by them together with any information they may have regarding me, including motor vehicle records, military records, financial status, criminal record, and general reputation, and I hereby release such companies or persons, the City of Littlefield, its management and elected officials from all liability, claims and damages in connection with the furnishing of such information. Ifurther acknowledge    that my employment may be terminated, and any offer of employment, if such is made, may be withdrawn with or without cause, at the option of the city or by me. Ifurther acknowledge that the foregoing completed application form does not in any way constitute a contract of employment. In the event I am hired, I understand and agree that my employment with the City ofLittlefield will be "at will", and that myself or the City ofLittlefield can terminate my employment at any time for any The City ofLittlefield is an equal opportunity employer and does not discriminate on the basis  reason or for no reason.  ofrace, creed, color, national origin, gender, religion or disability.  Date:  Signature:  Job applications expire Fiscal Year+2 2years from the above date.