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2. Applicant Information
4. Name
5. Date
   Date
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Email Address
16. Date Available
    Date Available
17. Date of Birth
    Date of Birth
19. Are you a citizen of the United States?

    1. Yes
    2. No
20. If no, are you authorized to work in the U.S.?

    1. Yes
    2. No
22. Have you ever been convicted of a felony?

    1. Yes
    2. No
23. If yes, explain:
25. Have you ever worked for the City of East Chicago?

    1. Yes
    2. No
26. If yes, what department?
30. Education
32. High School
33. Address
35. Term
    Term Start Date

    —

    Term End Date
36. Did you graduate?

    1. Yes
    2. No
37. Degree
39. College
40. Address
42. Term
    Term Start Date

    —

    Term End Date
43. Did you graduate?

    1. Yes
    2. No
44. Degree
46. Other Education
47. Address
49. Term
    Term Start Date

    —

    Term End Date
50. Did you graduate?

    1. Yes
    2. No
51. Degree
55. References
    Please list two references.
57. Full Name
58. Relationship
60. Company
61. Phone Number
63. Address
65. Full Name
66. Relationship
68. Company
69. Phone Number
71. Address
75. Desired Position
    In the order of your preference list three positions that you wish to be considered for the summer employment. Submitting your preference does not guarantee the position. (i.e. Lifeguard, Recreation Leader, Basket Attendant, or Labor)
77. 1st Priority Position
79. 2nd Priority Position
81. 3rd Priority Position
85. Previous Employment
87. Company
88. Phone
90. Address
91. Supervisor
93. Job Title
94. Starting Salary
95. Ending Salary
97. Responsibilities
99. Term
    Term Start Date

    —

    Term End Date
100. Reason for Leaving
102. May we contact your previous supervisor for a reference?

     1. Yes
     2. No
104. Company
105. Phone
107. Address
108. Supervisor
110. Job Title
111. Starting Salary
112. Ending Salary
114. Responsibilities
116. Term
     Term Start Date

     —

     Term End Date
117. Reason for Leaving
119. May we contact your previous supervisor for a reference?

     1. Yes
     2. No
123. Military Service
125. Branch
126. Term
     Term Start Date

     —

     Term End Date
128. Rank at Discharge
129. Type of Discharge
131. If other than honorable, explain:
135. Disclaimer & Signature
137. The City of East Chicago is an equal opportunity employer. The City does not discriminate in employment, and questions on this application are not used for the purpose of limiting or excluding any applicant’s consideration for employment unless prohibited by local, state or federal law.
     
     If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
     
     I hereby affirm that the information provided on this application is 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 dismissal if discovered at a later date.
139. Electronic Signature Agreement
140. Date
     Date
Leave This Blank:


142. 1. Receive an email copy of this form.
143. Email address

     This field is not part of the form submission.

144. Submit

* indicates a required field