City of Shoreline Human Resources Department 17500 Midvale Ave North Shoreline, WA 98133-4921 Website: www.shorelinewa.gov Email: hradmin@shorelinewa.gov 206-801-2243 phone / 206-546-1453 fax

APPLICATION FOR EMPLOYMENT

Please print clearly & complete all information. An incomplete application may delay processing or disqualify you. You may attach a resume, but a resume cannot be substituted for a completed application.

POSITION APPLYING FOR (Only one position allowed per application – Please do not submit more than one application for the same position)
Last Name	First Name	Middle Initial
Address	City	State	Zip Code
Telephone NumberHome	Telephone NumberCell	Telephone NumberWork/Other	Date of Application
Email Address

If you are under eighteen (18) years of age, can you provide

proof of your eligibility to work?

Have you ever been employed by the City of Shoreline?

If yes, give date(s):

Position:

Are you currently employed?

Are you currently working for or otherwise associated with a firm

who does business with the City of Shoreline?

If yes, give name of firm:

Firm’s association with City:

Are you legally authorized to work in the United States?

(Proof will be required upon employment)

Are you available to work:

Can you perform the essential functions of the job with or without a reasonable

accommodation?

The City of Shoreline provides equal employment opportunity for all applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, marital status or disability (as defined under state and federal law).

EMPLOYMENT HISTORY

List your complete employment history. If you need more space, attach additional sheets. Not completing this section (including Work Performed) could disqualify your application.

Start with your current or last job

Employer	Dates Employed	Work Performed
From	To	(include number & titles of any employees supervised)
Address
Telephone Number(s)	Hourly Rate/Salary
Starting	Final
Job Title	Supervisor Name/Title
Reason for Leaving
Employer	Dates Employed	Work Performed
From	To	(include number & titles of any employees supervised)
Address
Telephone Number(s)	Hourly Rate/Salary
Starting	Final
Job Title	Supervisor Name/ Title
Reason for Leaving
Employer	Dates Employed	Work Performed
From	To	(include number & titles of any employees supervised)
Address
Telephone Number(s)	Hourly Rate/Salary
Starting	Final
Job Title	Supervisor Name/Title
Reason for Leaving

EMPLOYMENT HISTORY (continued):

Employer	Dates Employed	Work Performed
From	To	(include number & titles of any employees supervised)
Address
Telephone Number(s)	Hourly Rate/Salary
Starting	Final
Job Title	Supervisor
Reason for Leaving
Give dates and explain all periods of unemployment over the last 10 years:
.

Special Skills and Qualifications List other activities which have provided you with experience, training or skills which you feel would be helpful in the position for which you are applying:

EDUCATION	High School/GED	Undergraduate College/University	Graduate/Professional
School Name & Location
Year Graduated (College & Graduate School Only)
Diploma/Degree
Course of Study (College & Graduate School Only)
Describe any applicable training, apprenticeship or extra-curricular activities
Honors received
State any additional educational information you feel may be helpful to us in considering your application

List professional, trade, business, or civic activities and offices held:

(You may exclude memberships which would reveal gender, race, religion, national origin, ancestry, sexual orientation, disability or other legally protected status.)

REQUIRED CERTIFICATIONS/LICENSES

Check the boxes of certifications/licenses you currently hold (this information will be used to screen your application)

Blood Borne Training Certificate	ICC Certification as Mechanical Inspector
Certified Records Manager	ICC Certification as Plans Examiner
Commercial Driver’s License: Type_______	Lifesaving Certification
Drivers License	Licensed Architect—Lic. No._____
First aid/CPR certificate	Membership in WA State Bar—Bar No._____
Flagging certificate	Municipal Clerk Certification
IAPMO Plumbing Certification	Pool Operator Certificate
ICC Certification as Building Inspector	Professional Engineer Registration No._____
ICC Certification as Building Official	Project Manager Certification
ICC Certification as Combination Inspector	WSI
Other	Other

CRIMINAL HISTORY INFORMATION

The City of Shoreline must consider an applicant’s conviction record as it relates to job performance. A conviction record will not necessarily disqualify you from employment unless it would reasonably relate to the duties of the job.

Have you been convicted of a crime, other than minor traffic violations, or released from prison within the last ten years?

If yes, indicate date, nature of offense, and disposition:

APPLICANT’S STATEMENT

I certify that the answers given herein are true and complete to the best of my knowledge.

I hereby give the City of Shoreline the right to check all employment related references and to make a thorough investigation of my past employment, education, and activities. The City reserves the right to contact additional employment related references that may have information regarding your ability to do this job. I release from liability all persons, companies and corporations supplying such information. I indemnify the City of Shoreline against any liability which might result from making such investigation. I understand that any falsification, misrepresentation, or material omissions on this application may result in denial of employment or discharge.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between the City of Shoreline and myself for any term of employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon the City of Shoreline unless made in writing by the City Manager or his/her authorized representative. Employees at the City of Shoreline are hired for indefinite terms of employment. No agent or representative of the City of Shoreline other than the City Manager, and then only in writing, has any authority to enter into any agreement for employment for any specified period of time.

______________________________________________ _________________________________

Signature of Applicant	Date

(You may fax or email application materials to hradmin@shorelinewa.gov as long as the application includes a valid signature)