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Executive Summary
This document is an employment application form for the City of Perth Amboy. It requires applicants to provide personal details, comprehensive employment history for their last four employers, skills and qualifications, educational background, and three professional or personal references. The application also includes sections for voluntary affirmative action information.
A notable requirement for employment is that all successful applicants must reside within the City of Perth Amboy, as stipulated by City Code Chapter 4-132. The application specifies that it remains current for a period of 60 days, after which a new application would be required for continued consideration.
The City of Perth Amboy is an Equal Opportunity Employer, committed to non-discrimination. Applicants requiring accommodations for the application or interview process are advised to contact the Personnel Department.
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Automated discovery link found on Perth Amboy website.
Document Text
--- Document: Apply Now Document ---
Application for Employment
AN EQUAL OPPORTUNITY EMPLOYER
Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodation to the
application and/or interview process should contact a representative of the Personnel Department.
PLEASE PRINT
Position(s) applied for ________________________________________________________ Date of application
/ /
Referral Source
Advertisement
Employee
Relative
Government Employment Agency
Walk-in
Private Employment Agency
Other __________________________
Name of Source (if applicable) ________________________________________________________________
Name _________________________________________________________________________________________________________
Last
First
Middle
Address _______________________________________________________________________________________________________
Street
City
State
Zip
Telephone Number __________________________________ Social Security Number
-
-
Email Address________________________________________________
Is a member of your immediate family* currently employed by the City?
Yes
No
May we contact you at work?
Yes
No Phone:
Time:
If you are under 18, can you furnish a work permit?
Yes No
Are you legally eligible for employment in this country?
Yes No
Date available for work
/
/
Type of employment
Full-Time
Part-Time
Temporary
Seasonal
Educational Co-Op
Are you on lay-off and subject to recall?
Yes No
Will you relocate if job requires it?
Yes
No Will you travel if job requires it? Yes No
Are you able to meet the attendance requirements of the position?
Yes No
Will you work overtime if required?
Yes No
Have you ever been bonded?
Yes No
Have you been convicted of a felony in the last seven (7) years?
Yes No
(Such conviction may be relevant if job related, but does not bar you from employment.)
If yes, please explain
Driver’s license number (if job-related)
State
*Immediate family includes spouse, child, parent, mother-in-law, father-in-law, stepparent, stepchild, sibling, half-sibling, step-sibling,
sister-in-law, brother-in-law, grandparents, daughter-in-law, son-in-law, grandchildren, niece, nephew, uncle, aunt, whether related by
blood, marriage, or adoption or any person related by blood, marriage, or adoption residing in your household.
AM
PM
City of Perth Amboy
260 High Street
Perth Amboy, NJ 08861
Employment History
List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience.
Explain any gaps in employment in comments section below.
Employer Telephone
( )
Dates Employed
Summarize the nature of the
Work performed and job responsibilities:
From
To
Address
Job Title
Hourly Rate/Salary
Starting
Immediate Supervisor and Title
$
Per
Reason for Leaving
Hourly Rate/Salary
Final
May we contact for reference? Yes No Later
$
Per
Employer Telephone
( )
Dates Employed
Summarize the nature of the
Work performed and job responsibilities:
From
To
Address
Job Title
Hourly Rate/Salary
Starting
Immediate Supervisor and Title
$
Per
Reason for Leaving
Hourly Rate/Salary
Final
May we contact for reference? Yes No Later
$
Per
Employer Telephone
( )
Dates Employed
Summarize the nature of the
Work performed and job responsibilities:
From
To
Address
Job Title
Hourly Rate/Salary
Starting
Immediate Supervisor and Title
$
Per
Reason for Leaving
Hourly Rate/Salary
Final
May we contact for reference? Yes No Later
$
Per
Employer Telephone
( )
Dates Employed
Summarize the nature of the
Work performed and job responsibilities:
From
To
Address
Job Title
Hourly Rate/Salary
Starting
Immediate Supervisor and Title
$
Per
Reason for Leaving
Hourly Rate/Salary
Final
May we contact for reference? Yes No Later
$
Per
Comments ( including explanation of any gaps in employment )
Skills and Qualifications – Summarize any special training, skills, licenses, certificates and/or characteristics of yourself that may
qualify you as being able to perform job-related functions for the position which you are applying
Educational Background (if job related)
A. List last three (3) school attended, starting with most recent. B. List number of years completed. C. Indicate degree or diploma
earned, if any. D. Grade Point Average or Class Rank and E. Major and minor field of study (if applicable).
A. School
B. Years
Completed
C. Degree
Diploma
D. GPA
Class Rank
E. Major
E. Minor
List any foreign language(s) you know and check the boxes that describe your skill level.
Language
Speak Some
Speak Fluently
Read
Write
References
List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not
applicable, list three school or personal references that are not related to you.
Name
Telephone
Years Known
Area Code
( )
Area Code
( )
Area Code
( )
List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race,
religion, national origin, age, color, disability or other protected status.)
Organization
Offices Held
List special accomplishments, publications, awards (exclude information which would reveal sex, race, religion, national origin, age,
color, disability or other protected status.)
List any additional information you would like us to consider.
It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this
application and/or separation from the employer’s service if I have been employed.
I give the employer the right to investigate all references and to secure additional information about me, if job-related. I hereby release
from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for
furnishing such information.
The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application
is used for purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal
law.
This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be
considered for employment, it will be necessary to fill out a new application.
I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or
without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to
the contrary.
I understand it is this company’s policy not to refuse to hire a qualified individual with a disability because of this person’s need for an
accommodation that would be required by the ADA.
All persons to be employed shall reside within the City of Perth Amboy, City Code Chapter 4-132
Signature of Applicant
Date
/
/
Affirmative Action Voluntary Information
(Completion of information below is voluntary)
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status or any
other legally protected status.
To be completed by applicant. Not for interview purposes. To be filed separately from application. This information is used to satisfy the Affirmative
Action requirements of Section 503 of the Rehabilitation Act or as necessitated by another federal law or regulation.
As required, we comply with government regulations including Affirmative Action obligations where they apply.
In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we ask that you
complete this applicant data survey. Your cooperation is appreciated.
Please be advised that this survey is not a part of your official application for employment. It is considered confidential information that
will not be used in any hiring decision.
Position(s) applied for
Date
/
/
Referral Source
Walk-in
Government Employment Agency
Private Employment Agency
Employee
Relative
School
Advertisement – Source
Other
Name of person who referred you (if applicable)
Applicant Information
Name
( )
Last
First
Middle
Area Code
Phone
Address
Street
City
State
Zip
Male
Female
Please check one of the following Equal Employment Opportunity Identification Groups:
White
Black (not of Hispanic origin)
Hispanic
American Indian / Alaskan Native
Asian / Pacific Islander
Special Notice
Vietnam Era Veterans, Disabled Veterans and Individuals with physical or mental disabilities:
Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to
take affirmative action to employ and advance in employment qualified disabled veterans, veterans of Vietnam era and qualified
handicapped individuals.
You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation.
This information will be considered confidential. Refusal to provide this information will not adversely affect your consideration for
employment.
If you so wish to be identified, please check if any of the following are applicable:
Vietnam era Veteran (served between 1964-1975)
Disabled Veteran
Individual with a disability
For Personnel Department Use Only
Position(s) applied for
Available
Not Available
Other positions considered for
Hired
Yes
No
Position hired for
Date of hire
/
/
From the EEO classifications listed below, which one best describes the position filled
1. Officials and Managers
2. Professionals
3. Technicians
4. Sales Workers
5. Office and Clerical Workers
6. Craft Workers (skilled)
7. Operatives (semi-skilled)
8. Laborers (unskilled)
9. Service Workers
Notes
Completed by
Date
/
/
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Personnel Department
Department for accommodations · Personnel Department
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Timeline
First Discovered
Apr 28, 2026
Last Info Update
May 20, 2026
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