17 North Main Street
Medford , NJ 08055

Employment Application:

Date:_______________________

Applicant Information:

Name (Last, First, Middle): ________________________________________________

Address:________________________________________________________________

City/Town:______________________________________________________________

Phone (Work): ( )_____________________ (Home): ( )__________________

Social Security Number:________________________________

Position applied for:______________________________________________________

Have you ever applied to the Township of Medford before: ______Yes _______ No

If yes, give date____________

Date you can start:________________________ Salary desired:__________________

Are you available to work: Full time____ Part time____ Temporary____ Seasonal_____

Are you currently employed: ____Yes _____ No

May we contact you at work: ____Yes _____ No

May we contact your current employer: ____Yes _____ No

Are you currently on layoff status and subject to recall: ____Yes _____ No

Do you possess a current driver’s license: ____Yes _____ No

Do you possess a current commercial driver’s license: ____Yes _____ No

Please list any endorsements: _____________________________________

If you are under eighteen years of age, can you provide proof of eligibility to work Yes/No

Are you legally eligible to work in the United States of America : ____Yes _____No
Pursuant to Federal Law, proof of US Citizenship or immigration status will be required if
you are hired.

Have you ever been found guilty of a crime; disorderly persons offense; or a municipal
ordinance that would bear a relationship to this job.

Employment is conditional upon the results of the criminal background check. An answer
of “Yes” may disqualify you from employment depending upon the circumstances
involved. If “Yes”, please explain below.

_____________________________________________________________________________
_____________________________________________________________________________

The Township of Medford is an Equal Opportunity Employer M/F

Employment History: This section must be completed even if you attach a resume. List your last four employers, major assignments
within the same employer. Begin with the most recent. Include any military service. Explain any gaps in employment in the space on
this form marked comments located on the bottom of this page.

Employer:____________________________________________________________________

Address:______________________________________________________________________

Date started:___________________ Date left:______________________

Starting Salary:_________________ Final Salary:___________________

Job Title: _______________________________________

Reason for leaving:_____________________________________________________________

Supervisor’s name and phone number: ____________________________________________

May we contact for a reference: _______Yes ______No

Employer:____________________________________________________________________

Address:______________________________________________________________________

Date started:___________________ Date left:______________________

Starting Salary:_________________ Final Salary:___________________

Job Title: _______________________________________

Reason for leaving:_____________________________________________________________

Supervisor’s name and phone number: ____________________________________________

May we contact for a reference: _______Yes ______No

Employer:____________________________________________________________________

Address:______________________________________________________________________

Date started:___________________ Date left:______________________

Starting Salary:_________________ Final Salary:___________________

Job Title: _______________________________________

Reason for leaving:_____________________________________________________________

Supervisor’s name and phone number: ____________________________________________

May we contact for a reference: _______Yes ______No

Employer:____________________________________________________________________

Address:_____________________________________________________________________

Date started:___________________ Date left:______________________

Starting Salary:_________________ Final Salary:___________________

Job Title: _______________________________________

Reason for leaving:_____________________________________________________________

Supervisor’s name and phone number: ______________________________________________

May we contact for a reference: _______Yes ______No

Comments: ___________________________________________________________________

Education: Provide information on your formal schooling and education. Please tell us the
highest grade you have completed and the names of all schools attended.

Elementary:____________________________ Graduated: Yes/No

High School:____________________________ Graduated: Yes/No Field:_______________

College:________________________________ Graduated: Yes/No Field:_______________

Other:_________________________________ Graduated: Yes/No Field:________________

Special Skills & Experience: State any special skills, experience, training, licenses,
certifications or other factors that make you especially qualified for the position for which
you are applying.

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Comments & Additional Information: is there any additional information about you we
should consider?

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

References: Provide the names, addresses and phone numbers of three people whom we
may contact as a reference. They should not be relatives or former supervisors.

Name & Address: Phone Number: Years Known:

1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
Understandings and Agreements:

As an applicant for a position with the Township of Medford , I understand and agree that I must
provide truthful and accurate information in this application. I understand that my application may be rejected
if any information is not complete, true and accurate. If hired, I understand that I may be separated from
employment if the Township of Medford later discovers that information on this form was incomplete,
untrue, or inaccurate. I give the Township of Medford the right to investigate the information I have
provided, talk with former employers (except where I have indicated they may not be contacted). I give the
Township of Medford the right to secure additional job-related information about mc. I release the Township
of Medford and its representatives from all liability for seeking such information. I understand that the
Township of Medford is an equal opportunity employer and does not discriminate in its hiring practices.
I understand that the Township of Medford will make reasonable accommodations as required by the
Americans with Disabilities Act. I understand that, if employed I may resign at any time and that the
Township of Medford may terminate me at any time in accordance with its established policies and
procedures no representatives of the Township of Medford may make any assurances to the contrary. I
understand that any offer of employment may be subject to job-related medical, physical, or drug. I also
understand that some positions may involve complete background and criminal checks.

Applicant’s Signature________________________________________________ Date ________________