CITY OF CONWAY

EMPLOYMENT APPLICATION
AN EQUAL OPPORTUNITY EMPLOYER

The City of Conway is an Equal Opportunity Employer and does not discriminate on the
basis of race, color, religion, sex, national origin, marital or veteran status, political status,
disability status or other legally protected status.

Instructions:
 Fill out the application completely
 At date of hire: Firefighters must be between 21 and 32 years of age; Police must be at least 21 years of age.
 Applicant must have a valid Arkansas driver’s license

PERSONAL: Driver’s License State: Driver’s License Number:

Name: (Last, First, Middle) Social Security #: Today’s Date:

Address: (Number, Street, City, State, Zip) Home Phone: Work Phone:

Position Applying For: Referred By: Date Available:

Full Part Time

Have you ever worked for the City of Conway before? Yes No If Yes, give dates of employment, job and your name at
the time of employment:

Do you have any relatives employed by the City of Conway? Yes No If yes, please give all names and relationships to
you:

Have you ever been convicted of a felony, or discharged from military service with other than an honorable discharge? Yes
No If yes, state the facts:

NOTE: A conviction record will not necessarily be a bar to employment. Factors such as age and time since the offense, seriousness and
nature of the violation, and rehabilitation will be taken into account.
EDUCATION Name & Location of School Years Completed Diploma or Degree Received

High School

Tech/Vocational School

College

Special Skills and/or Licenses Held:

U. S. MILITARY EXPERIENCE
Branch Dates of Service Highest Rank Held and Military Occupation
EMPLOYMENT HISTORY: (Begin with present or most recent employer)
Time Employed Name & Address of Employer & Immediate Position Held and Job Duties Base Salary
Supervisor
From: Mo. Yr. Company: $
Address:
To: Mo. Yr. per
City/State:
Total Time: Telephone:
Supervisor:
Reason for Leaving:

Time Employed Name & Address of Employer & Immediate Position Held and Job Duties Base Salary
Supervisor
From: Mo. Yr. Company: $
Address:
To: Mo. Yr. per
City/State:
Total Time: Telephone:
Supervisor:
Reason for Leaving:

Time Employed Name & Address of Employer & Immediate Position Held and Job Duties Base Salary
Supervisor
From: Mo. Yr. Company: $
Address:
To: Mo. Yr. per
City/State:
Total Time: Telephone:
Supervisor:
Reason for Leaving:

May we contact your present employer for a reference? Yes No

REFERENCES: Give names of three persons not relatives or former employers

Name Address Occupation Phone Number

AGREEMENT: Please read the following statement carefully

I understand that this application will remain active for 90 days only. I declare that my answers to the questions on this application are
true, and give the City of Conway the right to investigate all references and secure additional information necessary. I understand that the
use of this form does not indicate there are positions open and does not in any way obligate the City of Conway. I understand that
falsification of information on this application or in any interview(s) constitutes reason for cancellation of my application or termination of
my employment. I understand and agree that if I am employed, I will be employed “at will”. Either the City or I may end the employment
relationship at any time, for any reason. No representative of the City has the authority to change this agreement. I understand that I am
required to abide by all rules and regulations of the City of Conway. I also declare that by signing this employment application, I certify I
am in compliance with the Military Selective Service Act. This completed application form is subject to release under FOIA.

Signature of Applicant: _________________________________________ Date: _________________________

Submit to:
Human Resources
1201 Oak Street
Conway, AR 72032
Phone: 501-450-6102
Submit e-Mail
Fax: 501-358-6325
501-513-3503 Revised
Revised 10/2014
02.25.2015