application Employment 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 NumberAre 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 PhoneDo you reside within the Village of Princeville? Yes No 3. EducationSelect highest grade completed 9 10 11 12 12+ Name and City of last school attended Date attendedFrom Month Day Year To Month Day Year Are you still attending school? Yes No Special Training Are you now or have you previously served in the armed forces? 4. HealthDo 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 limitations5. Employment History Give a complete account of your previous employment, including military service. List your most recent employer first.Start Date Month Day Year End Date Month Day Year Company Address PhoneName of Supervisor Reason for leaving Describe other relevant experiences, hobbies, special qualifications or volunteer work that you have had6. References (List 3 references, other than relatives) Name Address Phone Years Known Business Relationship1. 2. 3. 7. Lifeguard CertificationsDo 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