APPLICATION FOR EMPLOYMENT
TOWN OF NORTH HERO
PO BOX 38
NORTH HERO, VT 05474
(802) 372-6926
FAX (802) 372-3806
Date of Application: ____________
PERSONAL INFORMATION:
Name: ___________________________________________________________
Mailing Address: ________________________________________________________
Phone: (Daytime) ________________________ (Evening) ______________________
Vermont Commercial Driver’s License __________ Yes _________ No
EDUCATION: (Check all that apply)
High School ____ GED ____ Tech School ____ College (Number of years) ____
WORK EXPERIENCE: (Provide dates and job description)
Company: ______________________________ Date from ___________ to ________
Job Description___________________________________________________
Company: ______________________________ Date from ___________ to ________
Job Description __________________________________________________
Company: _____________________________ Date from ___________ to ________
Job Description __________________________________________________
Company: _____________________________ Date from ___________ to ________
Job Description __________________________________________________
REFERENCES: (Three with complete mailing addresses & phone numbers)
Name: _____________________________ Phone no. ________________________
Address: _____________________________________________________________
Name: _____________________________ Phone no. ________________________
Address: _____________________________________________________________
Name: _____________________________ Phone no. ________________________
Address: _____________________________________________________________
Use reverse for additional information
Applicant’s Signature: __________________________________________________
DRIVER’S CONSENT FORM
DATE: ________________________
I ________________________________________, understand that
(Applicant’s Name)
_________________________________________ Insurance Company, which insures the Town
of North Hero will obtain copies of my driving records from various states through the
Department of Motor Vehicles. This search is done for purposes of underwriting insurance,
Adjusting claims and other purposes related to such insurance.
I hereby consent to Marketplace Insurance Center, Inc.; Agent/Broker, who will be obtaining
the Motor Vehicle Record, releasing such information to the Town of North Hero.
I understand that the Town of North Hero shall use such driving record in determining
whether to initiate or continue my employment with the Town of North Hero.
This consent shall be a continuing consent throughout the period during which I am an
applicant for employment with, or an employee of the Town of North Hero.
______________________________________
(Applicant Signature)