Employment Application

Bloom Township, Fairfield County, Ohio

Complete the fields below, then print or save as PDF and sign in ink. Submit by email or fax only — see the bottom of the form.

Position

Date

Position applying for (required)

Date available to start

Personal information

Name (required)

Address (required)

Home phone

Cell phone

Email address

Do you have a valid driver’s license?

YesNo

State

Driver license number

Do you have a valid CDL license?

YesNo

Has your driver license ever been suspended or revoked?

NoYes

If yes, explain (why and when)

Are you able to lift up to 75 lbs?

Available to work

Available to work — enter start and end times
Time	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Start time	Sunday Start time	Monday Start time	Tuesday Start time	Wednesday Start time	Thursday Start time	Friday Start time	Saturday Start time
End time	Sunday End time	Monday End time	Tuesday End time	Wednesday End time	Thursday End time	Friday End time	Saturday End time

Employment history

Employer 1

Employer

Address

Dates employed — from

Dates employed — to

Supervisor

Reason for leaving

Duties

Employer 2

Employer

Address

Dates employed — from

Dates employed — to

Supervisor

Reason for leaving

Duties

Employer 3

Employer

Address

Dates employed — from

Dates employed — to

Supervisor

Reason for leaving

Duties

Professional references

Reference 1 — name

Title

Phone

Reference 2 — name

Title

Phone

Reference 3 — name

Title

Phone

Certification (sign in ink after printing)

I certify that all information furnished in this employment application is true and complete to the best of my knowledge.

Print name

Signature

Date

Drug and alcohol testing acknowledgment

I acknowledge that Bloom Township has an Employee Drug Test Program, which requires employees to submit to drug and/or alcohol testing. I understand that should I be appointed to a position with Bloom Township, I may be required to participate in a drug and/or alcohol test during my employment. I further understand that should the test come back positive, I would be subject to appropriate disciplinary action up to and including termination. I hereby knowingly and voluntarily consent to drug and/or alcohol testing for pre-employment and during employment.

Print name

Signature

Date

Please submit your application by email or fax only:
Email: Administrator@bloomtwp.org | Fax: 614-837-7576

Please, no phone calls or office visits when submitting an application.