Passport Services
 

Starbucks in the Ferguson

Visa Status:

Do you have the legal right to live and accept employment in the United States?
Yes
No

If YES, do you have a social security number?
Yes
No

Have you ever applied for employment with this Library in the past?
Yes
No

If yes, enter month and year:

Results of Application:

Have you ever been convicted of a felony in the past 10 years?
Yes
No

If yes, describe in detail:

Note: In answering this question you are not required to disclose the existence of any arrest, criminal charge or conviction, the record of which has been erased pursuant to section 46b-146, 54-76o or 54-142a of the Connecticut statutes. These statutes involve records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a truthful offended, a criminal charge that has been dismissed or nolled, a criminal charge for which a person has been found not guilty or a conviction for which the person received an absolute pardon. You should also be aware that when a criminal record has been erased pursuant to the three statutes listed above, the person is deemed to have never been arrested within the meaning of the statutes and may so swear under oath.
 

You have been given access to a folder containing the job description of positions the Library is currently seeking to fill. Some of those jobs are also posted on the Library’s website. The open positions are numbered. Please list the job you want to be considered for by name and number:

Type of employment:
Temporary
Permanent
Part-time
Full-time
 

Days and Hours desired:

Are you willing to work overtime when required by your supervisor?
Yes
No

When can you start to work?

Please list any special training, skills or licenses which you possess and which should be considered when reviewing your application:

Education

High School (please list Name, Location, Years Completed, If you Graduated, and Degree or Diploma):

College, University, Technical School (please list Name, Location, Years Completed, If you Graduated, and Degree or Diploma):

Other Schools or Special Courses (please list Name, Location, Years Completed, If you Graduated, and Degree or Diploma):

Work Experience and Professional References

A. Please give complete and accurate information regarding your most recent full-time and part-time employment. Start with your present or most recent job:

1. Employer's Name, Address, Position Held, Telephone, Employment Dates, Reason for Leaving:

2. Employer's Name, Address, Position Held, Telephone, Employment Dates, Reason for Leaving:

3. Employer's Name, Address, Position Held, Telephone, Employment Dates, Reason for Leaving:

B. (Optional) Please provide the name, address and telephone number of two professional references:

REFERENCE CHECKS – We may want to contact the references you listed on the previous page. Do you object? If so, identify the Employer by number and tell us why you do not want us to make contact:

ADDITIONAL INFORMATION – Please provide any additional information you would like us to consider, including membership in professional or civic organizations, special accomplishments, awards, etc:

ACKNOWLEDGEMENT

• By signing this application, I declare that the information provided by me is complete and accurate to the best of my knowledge. I understand that any omission or misrepresentation on this application will constitute sufficient cause for rejection of this application or withdrawal of an offer of employment, or may result in my discharge from employment if I am already employed at the time the omission or misrepresentation is discovered.
• I authorize the Library to contact and obtain information about me from previous employers and references I have listed. To assist in the processing of this application, I waive all rights and claims I may otherwise have against the Library or its employees, agents and representatives, if any, for obtaining and using information to evaluate my application, as well as against all other persons, corporations or organizations who provide information for this purpose.
• This application is not an employment agreement. If I accept an offer of employment, I recognize that it is employment-at-will and may be terminated at any time, with or without cause or prior notice, unless otherwise provided by law or contract.

I UNDERSTAND AND FULLY ACCEPT THE TERMS AND CONDITIONS SPELLED OUT ABOVE.
 

Note: Please fill out this form completely and accurately. Incomplete or unsigned forms will not be processed.

Applicants will be considered without discrimination based on race, creed, color, sex, age, marital status, national origin, handicap, veteran status or any other status protected by applicable law.