tOWN OF WALPOLE employment Application

PO Box 729

Walpole, NH 03608

Applicant Information

Last Name

First

M.I.

Date

Street Address

Apartment/Unit #

City

State

ZIP

Phone

E-mail Address

Date Available

Social Security No.

Desired Salary

Position Applied for

Are you a citizen of the United States?

YES

NO

If no, are you authorized to work in the U.S.?

YES

NO

Have you ever worked for this company?

YES

NO

If so, when?

Have you ever been convicted of a felony?

YES

NO

If yes, explain

Education

High School

Address

From

To

Did you graduate?

YES

NO

Degree

College

Address

From

To

Did you graduate?

YES

NO

Degree

Other

Address

From

To

Did you graduate?

YES

NO

Degree

References

Please list three professional references.

Full Name

Relationship

Company

Phone

( )

Address

Full Name

Relationship

Company

Phone

( )

Address

Full Name

Relationship

Company

Phone

( )

Address

Previous Employment
Company					Phone	( )
Address					Supervisor
Job Title			Starting Salary		$			Ending Salary			$
Responsibilities
From	To	Reason for Leaving
May we contact your previous supervisor for a reference?				YES	NO
Company					Phone	( )
Address					Supervisor
Job Title			Starting Salary		$			Ending Salary			$
Responsibilities
From	To	Reason for Leaving
May we contact your previous supervisor for a reference?				YES	NO
Company					Phone	( )
Address					Supervisor
Job Title			Starting Salary		$			Ending Salary			$
Responsibilities
From	To	Reason for Leaving
May we contact your previous supervisor for a reference?				YES	NO
Military Service
Branch							From			To
Rank at Discharge							Type of Discharge
If other than honorable, explain
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature									Date

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

The Town of Walpole believes in the principles and practice of equal opportunity. The Town of Walpole is an Equal Opportunity Employer and considers all qualified applicants and employees for hire, promotion, training, and all other employee action without regard to race, color, religion, age, national origin, ancestry, sex or sexual orientation, marital status, disability, citizenship, veteran status, or any other protected category under applicable federal, state or local laws.