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Executive Summary

This document is an application for employment with the City of Perth Amboy. It outlines the city's equal opportunity employment policy, requests standard applicant information such as contact details, employment history, educational background, and references. The application also includes an Affirmative Action Voluntary Information section.

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--- 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 
 
/ 
/