application

1. Position Preference (check one)

Lifeguard
Assistant Manager
Manager

2. Personal

First Middle Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number

Are you at least 16 years of age?

Yes
No

Have you ever worked for the Village?

Yes
No

If yes, state position

Do you have relatives employed by the village?

Yes
No

If yes, state position:

Person to notify in case of emergency:

Name

Phone

Do you reside within the Village of Princeville?

Yes
No

3. Education

Select highest grade completed

Name and City of last school attended

Date attended

From

MM

DD

YYYY

To

MM

DD

YYYY

Are you still attending school?

Yes
No

Special Training

Are you now or have you previously served in the armed forces?

4. Health

Do you have any physical conditions or disabilities which might prevent you from doing certain kinds of work?

Yes
No

If yes, describe such limitations or disabilities and specific work limitations

5. Employment History

Give a complete account of your previous employment, including military service. List your most recent employer first.

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Company

Address

Phone

Name of Supervisor

Reason for leaving

Describe other relevant experiences, hobbies, special qualifications or volunteer work that you have had

6. References (List 3 references, other than relatives)
Name Address Phone Years Known Business Relationship

1.

2.

3.

7. Lifeguard Certifications

Do you have a lifeguard certificate from American Red Cross?

Yes
No

If yes, please provide a copy of your certificate to the Princeville Village Hall.

Do you have a Water Safety Instructor Certificate?

Yes
No

If yes, please provide a copy of your certificate to the Princeville Village Hall.

Have you had any other training in swimming?

Yes
No

If yes, please explain:

I am willing to have a medical examination. I authorize my former employers and listed references to give information concerning me, whether or not it is in their records, and I release them and their companies from any liability whatsoever. I certify that all statements given on this application are correct, and realize that falsification or misrepresentation of this or any other personal record may prevent employment, I agree to abide by all present and subsequently issued rules of the Village of Princeville.

Signature

Date

Employment Application