APPLICATION FOR EMPLOYMENT

FOR OFFICE USE ONLY
CERTIFIED POSITION DEPARTMENT
Date: __________	___________	___________
Date: __________	___________	___________
Date: __________	___________	___________

FOR OFFICE USE ONLY

Grade & Rank ____________________________

Position __________ Department ___________

Rate _____________ Hired __________________

APPLICATION FOR EMPLOYMENT

MEDINA CIVIL SERVICE COMMISSION

Be sure to complete the entire application. Once submitted, employment applications are subject to all applicable public record laws.

Last Name	First		M.I.	Date
Street Address			Apt/Unit #
City	State		ZIP
Phone	E-mail Address
Date Available	Social Security No.		Disclosure of your social security number is voluntary. If given, it could be used to obtain background information.
Position Applied for

Are you a citizen of the United States?		If no, are you authorized to work in the U.S.?
Were you previously employed by us?		If so, when & what position?
Have you ever been convicted of a felony or presently under indictment?		If yes, explain
Have you been convicted of a misdemeanor involving theft, dishonesty, or violence in the past ten years		If yes, explain
Are you able to perform the essential functions of the job you are applying for?
If you are asked to demonstrate your ability, are you willing to do so if reasonable accommodations are made?		All reasonable requests for ADA assistance during the testing process must be submitted in writing with your application.
Applicants for employment are evaluated and selected on the basis of individual merit and ability with respect to the position being filled. It is our policy is to provide equal employment opportunity in all aspects of employment without discrimination based on age, race, creed, color, national origin, gender (including pregnancy), sexual orientation, disability, marital status, Vietnam Era Veteran status, genetic predisposition, or carrier status.
Date of Birth (if applicable for position, e.g. police officer, firefighter)
Do you possess a valid State of Ohio Driver’s License?		If yes, what is your Driver’s License #
(if position requires driving, you must be insurable under the City of Medina’s vehicle insurance plan) Commercial Driver’s License (CDL) Type & Endorsements (if applicable for position, e.g. Motor Equipment Operator)

EDUCATION

High School

Address

Did you graduate?

Degree

College

Address

From

Did you graduate?

Degree

Other

Address

From

Did you graduate?

Degree

REFERENCES

Please list three professional references.
Full Name					Relationship
Address					Phone
Full Name					Relationship
Address					Phone
Full Name					Relationship
Address					Phone

PREVIOUS EMPLOYMENT (THIS SECTION MUST BE FULLY COMPLETED, EVEN IF ATTACHING A RÉSUMÉ)
Please list below all work-related experience, starting with the most recent employment and working backwards

Current or Most Recent Employer			Phone
Address			Supervisor
Job Title		Starting Salary $		Ending Salary $
Responsibilities
From	To	Reason For Leaving
Employer			Phone
Address			Supervisor
Job Title		Starting Salary $		Ending Salary $
Responsibilities
From	To	Reason For Leaving
Employer			Phone
Address			Supervisor
Job Title		Starting Salary $		Ending Salary $
Responsibilities
From	To	Reason For Leaving
May we contact all your current supervisor for a reference?
May we contact all your current supervisor for a reference?

MILITARY SERVICE

Branch	From	To
Rank at Discharge	Type of Discharge
List duties in the service including special training

NOTE: certification of honorable discharge, or a certified copy, must be presented for verification in order to receive extra credit on exam

Date Verified:_______________________ By Signature & Title: ___________________________________________

LIST OTHER SKILLS AND QUALIFICATIONS NOT NOTED THAT ARE PERTINENT TO THIS POSITION FOR WHICH YOU HAVE APPLIED:

APPLICANT STATEMENT AND SIGNATURE

The facts set forth above in my application are true and complete.
I understand that if employed, or considered for employment, false statements on this application shall be considered sufficient cause for removal. I understand, also, that I am required to abide by all rules and regulations of the Medina City or Medina City Schools.
I expressly authorize, without reservation, to make any investigation of my personal history and financial and credit record through any investigative or credit agencies or bureaus of your choice. In making this application, I also understand that information may be obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. I understand that I have the right to submit a written clarification of any adverse or incorrect information in my application file.
I understand that if I am hired for a position that involves driving Medina City or Medina City School vehicles, I must possess and maintain a valid State of Ohio driver's license and remain insurable under the City or Schools vehicle insurance plan, and will be subject to spot checks regarding same.
I understand that the City of Medina or Medina City Schools may require me to successfully complete and pass a pre-employment drug screen and/or alcohol test as a condition of employment and that continued employment may be based on the successful completion and passage of similar tests.
If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate any employment at any time, with or without cause and without prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration.
Once this employment application is submitted, I understand that it becomes a public record along with all test scores and results.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

*The parties acknowledge and agree that this application may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via pdf) of an original signature.

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Your legal name

Your email address

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Timestamp

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May 18, 2025 8:24 pm EST

APPLICATION FOR EMPLOYMENT Uploaded by Kim Leightner - [email protected] IP 136.52.53.247