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1. Step One (current) This section is complete This section is incomplete
2. TOWN OF CHINO VALLEY EMPLOYMENT APPLICATION This section is complete This section is incomplete
3. Position Information This section is complete This section is incomplete
4. Personal Information This section is complete This section is incomplete
5. Education This section is complete This section is incomplete
6. Employment History This section is complete This section is incomplete
7. APPLICANT CONSENT AND RELEASE This section is complete This section is incomplete
8. CRIMINAL HISTORY RECORD This section is complete This section is incomplete
9. VOLUNTARY PERSONAL INFORMATION QUESTIONNAIRE This section is complete This section is incomplete

Step One

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TOWN OF CHINO VALLEY EMPLOYMENT APPLICATION

202 N. State Route 89
Chino Valley, AZ 86323
(928) 636-2646 Office
(928) 636-9129 Fax
An Equal Opportunity Employer
It is the policy of the Town of Chino Valley to provide equal opportunity employment. Selection and employment of applicants shall be made on the basis of qualifications without regard to age, disability, national origin, race, color, sex or religion. If hired, you will be required to furnish proof of your eligibility to work in the United States.
Date
Date

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Position Information

Which position are you applying for?
Type of employment desired*
Full Time
Part Time
Temporary
Work Holidays?
Yes
No
Work Weekends?
Yes
No
When could you start work?
Salary requirements*
Upload Your Resume

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Personal Information

Instructions
Please answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discriminations based upon non job-related information.
Last Name*
First Name*
Address1*
Address2
City*
State*
Zip*
Phone Number*
Email Address*
How did you hear about this position?*
Do you have the legal right to work in the U.S.?*
Yes
No
Have your ever worked for the Town of Chino Valley?*
Yes
No
If YES, when and what position
Have you ever been employed under another name?*
Yes
No
If YES, please list
Have you ever applied here belore?*
Yes
No
If YES, please list
Have you ever been convicted of any law violation? (Include any plea of "guilty" or "no contest". Exclude minor traffic violations.)*
Yes
No
If YES, please explain and give location. Convictions are evaluated in relation to a position and will not necessarily disqualify employment.
Are you 18 years of age or older?*
Yes
No
Do you have a valid driver's license?
Yes
No
If YES, please list number. Please include CDL information if applicable.
Have you had your driver's license suspended or revoked in the last three years?
Yes
No
If YES, give details
Have you ever been discharged from employment?
Yes
No
If YES, please explain
Do you have relatives working for the Town of Chino Valley?*
Yes
No
If YES, Name and Department
If employed, do you expect to be engaged in any additional business or employment outside of this position?*
Yes
No
If YES, give details

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Education

High School
Address
College
Degree
Address
Other
License/Professional Certifications
Address
What skills or additional training do you have that relate to the job for which you are applying?
What machines or equipment can you operate that relate to the job for which you are applying?

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Employment History

Are you employed now?
Yes
No
May we contact your present employer?
Yes
No
Begin with most recent
Company
Address
City
State
Zip
Phone Number
Supervisor
Your Job Title
Responsibilities
Date Started
Salary
Date Left
Salary
Reason for Leaving
Other Information
Company
Address
City
State
Zip
Phone Number
Supervisor
Your Job Title
May we contact your previous supervisor for a reference?
Yes
No
Responsibilities
Date Started
Salary
Date Left
Salary
Reason for Leaving
Other Information
Company
Address
City
State
Zip
Phone Number
Supervisor
Your Job Title
May we contact your previous supervisor for a reference?
Yes
No
Responsibilities
Date Started
Salary
Date Left
Salary
Reason for Leaving
Other Information

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APPLICANT CONSENT AND RELEASE

The following information must be completed and submitted with the application.
BACKGROUND INVESTIGATION:
The term “background investigation” as used in this document refers to any and all information and sources of information that the Town of Chino Valley, Arizona (“Town”), in it sole discretion, may deem necessary to obtain or contact, to determine my fitness as a candidate for employment with the Town.
1. In accordance with the Town Personnel Policy and Administrative Guideline Manual Policies #200 and #205, all prospective employees of the Town are required to submit fingerprints to Human Resources for the purpose of obtaining a state and national criminal history records check by the Federal Bureau of Investigation, except prospective temporary and part-time employees who shall be employed less than ninety (90) days, unless such position requires working with children under eighteen (18) years of age.
2. I authorize any person or entity contacted by the Town’s officers, agents, and employees during the course of my background investigation, to furnish to such officers, agents, and employees any information or opinions they may have.
3. I hereby release from liability and hold harmless the Town and its agents, officers and employees for, from and against, any and all causes of action, claims, demands, suits, damages, costs, and debts, both in law and in equity which I may have, or in the future may have, of any nature whatsoever, including any and all claims arising from any statements, acts or omissions, or any information or opinions furnished to the employees of the Town as part of my background investigation.
4. I expressly agree that I will not, under any circumstances, attempt to obtain the results of my background investigation as conducted by the Town, realizing that such information must, of necessity, remain confidential.
DRUG TESTING AND HIPAA RELEASE AUTHORITY:
The town is committed to a drug-free workplace to protect the safety of workers and the public. It is the policy of the Town that applicants take a drug screen to show they are drug free.
1. In consideration for my being considered for employment by the Town, I give my consent to, and authorize, any Town designated collection site to perform any testing on my urine to determine the presence and/or level of any drug designated by the Town.
2. I give my consent for the release without restriction to the Town, of my individually identifiable health information or other medical records related to any medical tests. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). All physicians, employees, and agents who work or perform services for any Town designated collection site are held harmless from any action that may arise out of such test results being disclosed to the Town.
3. I understand and acknowledge that any of the following will constitute a violation of the drug policy for the Town: 1. Refusal to sign this or any related form. 2. Failure to appear to be tested. 3. Leaving the collection site for any reason prior to providing a sample. 4. The adulteration of any sample. 5. A positive test result
4. I understand and acknowledge that if I am employed by the Town, I am subject to the policies and procedures set forth in the Town of Chino Valley Personnel Policy and Administrative Guideline Manual, including, but not limited to, the policies regarding Drug and Alcohol Free Workplace and Testing.
AFFIRMATION OF POLICY AND CONDITION OF EMPLOYMENT - PLEASE READ CAREFULLY BEFORE SIGNING
In consideration of the Town processing my application for employment, I irrevocably agree to the above terms and conditions, and affirm that I have read and understand the meaning of the above statement of policy. This release from liability given by me to the Town and its employees, and all others as mentioned previously shall apply to any right of action of any nature whatsoever that might accrue to me, my heirs, my personal representatives, successors and assigns. I acknowledge that failure to pass the background investigation, a violation of the drug policy of the Town, or any other above stated conditions of employment will render me ineligible for employment with the Town for a minimum of one (1) year. Further, any prior conditional offer of employment will be withdrawn. I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release and hold harmless such persons and organizations from any legal liability in making such statements. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. I have read, understand, and by my signature consent to these statements.
Applicant's Signature*
Date*
Parent or Guardian**
Witness
Date
*If under 18, parent or guardian signature is required. I understand this authorization is valid for a period of two (2) years.

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CRIMINAL HISTORY RECORD

CRIMINAL HISTORY RECORD
The Town of Chino Valley conducts an extensive background investigation of criminal history. Please be very careful in completing this section. Human Resources will verify this information. A criminal record may not disqualify an individual from employment consideration of retention; however, FAILURE TO DISCLOSE ALL INFORMATION REQUESTED ON THIS FORM, will result in disqualification for employment with the Town of Chino Valley. For EACH OFFENSE, include month/year/location and complete disposition. For any conviction resulting in incarceration, provide dates and name of institutions.
Do you have any felony or misdemeanor convictions (including DUI) other than a civil traffic violation?*
Yes
No
*A “YES” response requires a complete explanation or your application will not receive further consideration. Please explain fully:
Traffic violations are included in the background results obtained through the criminal records check. If a good driving record is applicable to the position for which you applied, the results may negatively impact your employment with the Town of Chino Valley.
AFFIRMATION OF POLICY AND CONSENT AND RELEASE
I understand that should I fail to disclose all information requested in this form regarding convictions, my application will not receive further consideration and I will not be considered for employment for a minimum of one year. The complete results of the fingerprint criminal records check may not be available for two months or more. I further understand that if I obtain employment with the Town of Chino Valley and information is received regarding the conviction, which should have been disclosed on this form, but was not, I may be dismissed from employment with the Town.
Name*
Signature*
Date*

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VOLUNTARY PERSONAL INFORMATION QUESTIONNAIRE

The Town of Chino Valley is an equal opportunity employer. The following information is voluntary and necessary for statistical government record keeping and reporting purposes. This data is confidential and will NOT be included in your application. If will be separately retained and it will have NO bearing upon the process of considering you for employment.
Check One
Male
Female
Age Category
19 and Under
20-29
30-39
40-49
50 or Older
Ethnic Origin
Alaskan/American Indian
Black
Hispanic
White
Asian
Other
Veteran/U.S. Military Status
Yes
No
Active National Guard or Reservist
Yes
No

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Employment Application

Steps

Step One

TOWN OF CHINO VALLEY EMPLOYMENT APPLICATION

Position Information

Personal Information

Education

Employment History

APPLICANT CONSENT AND RELEASE

CRIMINAL HISTORY RECORD

VOLUNTARY PERSONAL INFORMATION QUESTIONNAIRE

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