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2. CITY OF OKMULGEE 

   AN EQUAL OPPORTUNITY EMPLOYER

4. INSTRUCTIONS: 

   The application must be completed even if you attach a resume. You must be able to substantiate all statements made. City of Okmulgee, P.O. Box 250, Okmulgee, OK 74447
6. DATE:*
   DATE:
7. Position you are applying for*

   1. Police Officer
   2. Street Department Equipment Operator
   3. Water Treatment Plant Operator
   4. Landfill Equipment Operator
   5. Mechanic's Assistant
9. First Name*
10. Middle Name*
11. Last Name*
13. Address*
14. City*
16. State*
17. Zip Code*
18. Email*
20. POLICE AND FIRE APPLICANTS ONLY :
21. Birth Date
    Birth Date
23. Are you over the age of 18?*

    1. Yes

    1. No
24. Are you applying for seasonal employment

    1. Yes

    1. No
26. Indicate all types of employment you will accept:*

    1. Full Time
28. Home Phone Number*
29. Cell Phone Number
30. Work Phone Number
32. Person who can contact you:
34. First Name*
35. Last Name*
37. Phone Number*
39. Do you have a legal right to work in this country?*

    1. Yes

    1. No
40. Do you have a valid driver's license?*

    1. Yes

    1. No
42. Have you ever worked for the City of Okmulgee?*

    1. Yes

    1. No
43. Do you have a CDL*

    1. Yes

    1. No
45. Position:*
46. Start to End Date
    Start to End Date Start Date

    —

    Start to End Date End Date
48. Are you Related to any City employee?*

    1. Yes

    1. No
50. First Name
51. Last Name
53. Relationship
54. Department
58. EMPLOYMENT HISTORY:
    Start with your present or last employment. It is important that complete information be given.
60. 1. Employer
61. Date Employed
    Date Employed
62. Date Separated
    Date Separated
64. Address
65. Total Years/Months Employed
66. Salary
68. City
69. Supervisor
70. Phone Number
72. State
73. Zip Code
74. Department
75. Your Title
77. Specific Duties:
79. Reason for Leaving:
81. Do you Have an additional previous employer to add?*

    1. Yes

    1. No
85. 2. Employer
86. Date Employed
    Date Employed
87. Date Separated
    Date Separated
89. Address
90. Total Years/Months Employed
91. Salary
93. City
94. Supervisor
95. Phone Number
97. State
98. Zip Code
99. Department
100. Your Title
102. Specific Duties:
104. Reason for Leaving:
106. Do you have an additional previous employer to add?

     1. Yes

     1. No
110. 3. Employer
111. Date Employed
     Date Employed
112. Date Separated
     Date Separated
114. Address
115. Total Years/Months Employed
116. Salary
118. City
119. Supervisor
120. Phone Number
122. State
123. Zip Code
124. Department
125. Your Title
127. Specific Duties:
129. Reason for Leaving:
131. Do you have an additional previous employer to add?

     1. Yes

     1. No
135. 4. Employer
136. Date Employed
     Date Employed
137. Date Separated
     Date Separated
139. Address
140. Total Years/Months Employed
141. Salary
143. City
144. Supervisor
145. Phone Number
147. State
148. Zip Code
149. Department
150. Your Title
152. Specific Duties:
154. Reason for Leaving:
156. Do you have an additional employer to add?

     1. Yes

     1. No
160. 5. Employer
161. Date Employed
     Date Employed
162. Date Separated
     Date Separated
164. Address
165. Total Years/Months Employed
166. Salary
168. City
169. Supervisor
170. Phone Number
172. State
173. Zip Code
174. Department
175. Your Title
177. Specific Duties:
179. Reason for Leaving:
181. Do you have an additional employer to add?

     1. Yes

     1. No
185. 6. Employer
186. Date Employed
     Date Employed
187. Date Separated
     Date Separated
189. Address
190. Total Year/Months Employed
191. Salary
193. City
194. Supervisor
195. Phone Number
197. State
198. Zip Code
199. Department
200. Your Title
202. Specific Duties:
204. Reason for Leaving:
208. Were you ever discharged or asked to resign from any position?

     1. Yes

     1. No
210. Why?
212. May we contact your present employer?

     1. Yes

     1. No
214. What knowledge, special technical or computer skills, and/or individual capabilities do you have which specially prepare you for the position you have applied for?
218. Have you ever been in the military service of the United States?

     1. Yes

     1. No
220. Branch of Service
221. Date of Service
     Date of Service
222. Discharge Date
     Discharge Date
224. Rank
225. Present membership in National Guard or Reserves?

     1. Yes
     2. No
226. Date obligation ends
     Date obligation ends
228. Other than traffic violations, have you ever been convicted of a crime?*

     1. Yes

     1. No
230. Describe in Detail
232. (NOTE: A conviction does not automatically disqualify you from employment.)
234. The City of Okmulgee adheres to the equal employment opportunity guidelines set forth by state and federal laws. All applications are considered for employment without regard to race, color, creed, religion, national origin, age, sex, disability or veteran status.
238. Education & Training
     Select Highest Grade Completed
240. High School
     -- Select One --123456789101112
241. College
     -- Select One --12345
242. Post Graduate
     -- Select One --1234
244. Did you graduate from high school?

     1. Yes

     1. No
245. GED?

     1. Yes

     1. No
247. Name and location of high school
249. Name of university or college
250. Major/Degree Received
252. Address
253. Dates Attended
     Dates Attended Start Date

     —

     Dates Attended End Date
255. City
256. Number of Hours
258. State
259. Zip Code
261. Name of other schools (Business, Trade, Tech.)
262. Major/Degree Received
264. Address
265. Dates Attended
     Dates Attended Start Date

     —

     Dates Attended End Date
267. City
268. Number of Hours
270. State
271. Zip Code
275. I certify that all the information submitted by me on this application is true, complete, and correct to the best of my knowledge, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be changed, with or without causeand with or without notice at any time by the City. I hereby authorize the investigation of all statements made in this application and hereby release from liability all persons, companies, or corporations supplying any information concerning me.
277. I understand and agree that employment with the City of Okmulgee is "at will", which means that either I or the City can terminate the employment relationship at any time, with or without cause, with or without prior notice, and for any reason not prohibited by statute. I understand that no representative of the City has any authority to enter into any agreement for employment for any specified period of time or make any agreement contrary to the terms set out in these paragraphs, unless specifically authorized in writing.
279. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
281. Electronic Signature*
282. Date*
     Date
284. Upload Resume
Leave This Blank:


286. 1. Receive an email copy of this form.
287. Email address

     This field is not part of the form submission.

288. Submit

* indicates a required field