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2. Date
   Date
3. Last Name:*
5. First Name:*
6. Middle Name:
8. Telephone No.:*
9. Email Address*
   Please provide your email address.
11. Address:*

    Must be a physical address where you reside, not a P.O. Box. 

13. City:*
14. State:*
15. Zip Code:*
17. Referring City Employee (Only List One):

    Please list the name of the City employee who first encouraged you to apply for this position. Listing more than one employee will disqualify them from incentive eligibility. If you were not referred, please leave this box blank.  

19. Do you have a valid Kansas driver's license?*

    1. Yes

    1. No
20. Do you have a valid Kansas commercial driver’s license (CDL)?

    1. Yes

    1. No
22. Title of position you are applying for:*
    Please be specific and do not respond "any".
24. Department you are applying for:
26. Type of position:*

    1. Full Time

    1. Part Time

    1. Summer

    1. Temporary
28. If part time, state days and hours you can work:
30. Date available to begin work:*
    Date available to begin work:
32. Education
34. High School Name and Location:
35. Graduated/Degree:
37. College Name and Location:
38. Graduated/Degree:
40. Other Education Name and Location:
41. Graduated/Degree:
43. If you did not complete high school and the job description requires it, do you have a GED?

    1. Yes

    1. No
45. If yes, give date received:
46. and place received:
48. List or describe any skills or school course(s) that you have that relate to the position for which you are applying:*
50. Have you ever been employed by the City of Independence?*

    1. Yes

    1. No
52. If yes, what department:
53. Date:
55. Have you ever worked under a different name?*

    1. Yes

    1. No
57. If yes, name used:
59. Do you have any relatives working for the City of Independence?*

    1. Yes

    1. No
61. If yes, in which department?
62. Relationship:
64. Have you ever been convicted of a felony?*

    1. Yes

    1. No
66. If yes, what year did it occur and what was the charge?
68. In what County and State did the conviction occur?
70. Employment History
72. 1. Company:
73. Position:
75. Address:
76. Phone:
78. Dates worked there:
79. Supervisor
81. Reason for leaving:
83. 2. Company:
84. Position:
86. Address:
87. Phone:
89. Dates worked there:
90. Supervisor:
92. Reason for leaving:
94. 3. Company:
95. Position:
97. Address:
98. Phone:
100. Dates worked there:
101. Supervisor:
103. Reason for leaving:
105. 4. Company:
106. Position:
108. Address:
109. Phone:
111. Dates worked there:
112. Supervisor:
114. Reason for leaving:
116. Would you object to having any of the above employers contacted in regard to your work experience?

     1. Yes

     1. No
118. If yes, explain:
120. Are you presently employed?*

     1. Yes

     1. No
122. If yes, why do you wish to leave?
124. Have you ever been a members of the Kansas Public Employees Retirement System, Firemen's System or the Kansas School Retirement System?*

     1. Yes

     1. No
126. If yes, give name of retirement system and a full explanation including dates of employment under other system:
128. Are you currently a member of a military reserve organization?

     1. Yes

     1. No
130. If yes, explain:
132. References
134. Give name, address, and phone number of three persons who have known you at least one year.
136. 1. Name:
137. Phone:
139. Address:
141. City:
142. State:
143. Zip:
145. 2. Name:
146. Phone:
148. Address:
150. City:
151. State:
152. Zip:
154. 3. Name
155. Phone:
157. Address:
159. City:
160. State:
161. Zip:
163. Upload your resume here:
165. IN CASE OF EMERGENCY, NOTIFY:
167. Name:
168. Phone:
170. Address:
172. City:
173. State:
174. Zip:
176. Relationship:
178. I HEREBY CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE AND CORRECT. I UNDERSTAND THAT THE CITY OF INDEPENDENCE, KS MAY RESEARCH ALL STATEMENTS AND CLAIMS MADE ON THIS APPLICATION AND MAKE REFERENCE CHECKS. IF RESEARCH SHOWS THAT FALSE INFORMATION WAS WILLFULLY GIVEN BY ME, IT SHALL BE CONSIDERED SUFFICIENT CAUSE FOR REJECTION OR DISMISSAL.
180. Please type your First and Last Name
182. Electronic Signature:
183. Date:
185. 1. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
187. OFFICIAL USE ONLY
189. Department:
190. Department Head:
Leave This Blank:


192. 1. Receive an email copy of this form.
193. Email address

     This field is not part of the form submission.

194. Submit Submit and Print

* indicates a required field