Seasonal Employment Application (PDF)

APPLICATION FOR SUMMER EMPLOYMENT 
TOWN OF WATERFORD 
Equal Opportunity Employer 
 
 
Page 1 
It  is  the  policy  of  the  Town  of  Waterford  to  provide  equal  opportunity  without  regard  to  race,  color,  sex,  gender, 
pregnancy,  age,  disability,  religion,  national  origin,  marital  status,  sexual  orientation,  ancestry,  gender  identity  or 
expression, or any other criteria protected under applicable federal and/or state law.  All questions must be answered 
and application signed. 
 
Last Name 
 
 
First 
 
 
 
Middle 
 
Date of Application 
Street Address 
Home Phone 
 
City, State, Zip 
Mobile/Cell Phone 
 
Email Address 
Work/Business Phone 
 
When is the best time to reach you? 
 AM   
 PM 
May we contact you at work? 
 Yes 
 No 
Have you ever worked for the Town of Waterford? 
 Yes   
 No 
If yes, indicate your dates of employment and reason(s) for leaving 
employment: 
 
 
Position Applying for: 
 Camp DASH  
 
 Beach Staff   
 Playground   
 
 Lifeguard 
To comply with American Red Cross standards, 
you must be 15 years of age or older to be 
employed as a lifeguard. 
I am 15 years of age or older:  
 Yes     
 No 
Are you under 18 years of age? 
 Yes   
 No 
If yes, state your date of birth:  
Month _______   Day _______    Year _______ 
Can you furnish a Statement of Age/Working Paper as appropriate? 
 Yes   
 No 
What date will you be available to begin work? 
 
Can you furnish proof of your right to work in 
the U.S.A.? 
 Yes  
 No 
Driver’s License Number:  
 
 
 
 
 
Special Endorsements? 
 Yes 
 No 
If yes, please describe: 
 
CDL License? 
 Yes 
 No 
If yes, please describe: 
 
 
If hired, is there anything which would prevent you from reporting to work each day on time and performing the 
essential functions of the position(s) applied for? 
 Yes   
 No 
If yes, please describe: 
 
 
Hours 
Available 
Sun 
Mon 
Tue 
Wed 
Thu 
Fri 
Sat 
Total Hours 
Available per Week 
FROM 
 
 
 
 
 
 
 
 
TO 
 
 
 
 
 
 
 

Page 2 
EDUCATIONAL BACKGROUND 
School 
Name and Location 
of School 
GPA or 
Class 
Rank 
Course of 
Study 
Number of 
Years 
Completed 
Did you 
Graduate? 
Degree or 
Diploma 
High School 
 
 
 
 
 
 
 Yes 
 No 
 
College 
 
 
 
 
 
 
 Yes 
 No 
 
Other 
 
 
 
 
 
 
 Yes 
 No 
 
Are you going to school now? 
 Yes 
 No 
If yes, do you take: 
 Day Classes 
 Evening Classes 
 
 
EMPLOYMENT HISTORY 
The Town of Waterford reserves the right to contact prior and current employers.  Please give an accurate, complete, 
full‐time  and  part‐time  employment  record.    Start  with  your  present  or  most  recent  employer.    Include  military 
experience, if applicable.  Do not indicate “see resume.” 
 
1 
Company Name and Mailing Address 
Business Phone 
 
Employed (Month and Year) 
 
From: 
 
 
To: 
 
 
Job Title and Name of Supervisor 
Reason for Leaving Employment 
 
 
 
 
 
Describe Your Work

Page 3 
 
2 
Company Name and Mailing Address 
Business Phone 
 
Employed (Month and Year) 
 
From: 
 
 
To: 
 
 
Job Title and Name of Supervisor 
Reason for Leaving Employment 
 
 
 
 
 
3 
Relatives: List the names of any and all relatives (blood or otherwise) who currently work for the Town of 
Waterford or the Waterford Public Schools.  If you know the title of the position held by your relative, please 
list the position. 
Name of Relative 
Nature of Relationship 
(e.g., mother, father, sister, etc.) 
Position Held 
1. 
 
 
 
2. 
 
 
 
3. 
 
 
 
 
 
4 
References: List the name, nature, address and telephone number of three references.  (References may not 
be related to you.) 
Name/Address 
Nature of Reference 
(e.g., personal, work, volunteer) 
Phone Number 
1. 
 
 
 
 
2. 
 
 
 
 
3. 
 
 
 
 
 
Describe Your Work

Page 4 
5 
Certifications & Special Training: List any and all Special Training and/or Certifications and the dates 
received. 
Special Training/Certification 
Date Initially 
Received 
Certification 
Current 
1. 
 
 
 Yes 
 No 
2. 
 
 
 Yes 
 No 
3. 
 
 
 Yes 
 No 
 
 
6  Please indicate any other relevant training and/or experience you have that is not listed above. 
 
 
 
 
 
 
 
 
 
7  Please list any relevant work and/or volunteer experience you have that is not listed above. 
 
 
 
 
 
 
 
 
 
8  Please list any special skills, training, interests or hobbies. 
 
 
 
 
 
 
 
 

Page 5 
9 
Please list any relevant courses, First Aid courses, related employment opportunities or experiences 
you have had. 
 
Date Completed 
Location 
Instructor 
Community Water Safety 
 
 
 
Lifeguard Training 
 
 
 
Head Lifeguard 
 
 
 
Waterfront Lifeguard 
 
 
 
Lifeguard Training Instructor 
 
 
 
Water Safety Instructor 
 
 
 
ARC Standard First Aid 
 
 
 
ARC Community First Aid and Safety 
 
 
 
ARC CPR for the Professional Rescuer 
 
 
 
AED Training 
 
 
 
Additional Training: 
 
 
 
 
 
 
 
 
 
 
 
DISCLOSURE AND ACKNOWLEDGMENT OF INTENT TO CONDUCT DRUG TEST 
 
Please be advised that prior to making a decision regarding your hire, the Town of Waterford may conduct a urinalysis 
drug test as part of the application process.  The urinalysis drug test will be performed using a reliable methodology.  
The results of any such test shall be confidential and shall not be disclosed by the employer or its employees to any 
person other than any such employee to whom such disclosure is necessary; the results shall be maintained along with 
other employee medical records. 
 
I certify by my signature below that I have read and reviewed the “Disclosure and Acknowledgment of Intent to Conduct 
Drug Test,” and I understand that I may be required to submit to a drug test as part of the application process. 
 
 
Date:    
 
 
 
 
 
Signature:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name:    
 
 
 
 
 
 
 
 
 
 
 
SIGN

Page 6 
DISCLOSURE AND ACKNOWLEDGMENT REGARDING DRIVING HISTORY INFORMATION 
REQUEST 
 
I  certify  by  my  signature  below  that  I  understand  that  if  I  am  offered  and  accept  employment,  a  driving  history 
information request shall be submitted. 
 
 
Date:    
 
 
 
 
 
Signature:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name:    
 
 
 
 
 
 
 
 
 
CERTIFICATION OF TRUTHFULNESS OF INFORMATION PROVIDED AUTHORIZATION TO 
REQUEST INFORMATION AND TO RELEASE INDIVIDUALS/ENTITIES WHO PROVIDE 
INFORMATION 
 
I certify that the information given herein is true and complete to the best of my knowledge.  I further acknowledge that 
falsification  or  omission  of  any  information  presented  or  requested  on  this  application  and/or  during  the  interview 
process may result in rejection of or dismissal from a position. 
 
I understand that this application will be active for a period of 60 days; after that time, if I wish to be considered for 
employment, I must submit a new application.  
 
I authorize you to make such investigations and inquiries of the information provided herein, and other matters that 
relate  hereto,  as  may  be  necessary.    I  hereby  release  employers,  schools  and  other  persons,  institutions  and 
businesses from all liability in responding to inquiries in connection with my application. I understand that false or 
misleading information given in my application or during my interviews may result in a refusal to hire, or discharge in 
the event of employment.  I understand and agree that, if hired, my employment is at will.  I also understand that if I 
am hired my employment is for no definite period of time.  I may terminate my employment at any time and I may be 
dismissed at any time without prior notice.  I further understand and agree that nothing in this application form shall 
constitute a contract of employment or shall constitute a contract or a guarantee of employment. 
 
I  also  understand  that  any  policies  or  procedures  implemented  by  the  Town  of  Waterford  in  the  event  of  my 
employment  are  for  purposes  of  operations  only  and  are  not  intended  to  be  nor  constitute  a  contract  for  my 
employment.  In addition, I understand that any of these policies or procedures may be changed at any time at the 
employer's discretion and without notice. 
 
 
Date:    
 
 
 
 
 
Signature:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Printed Name:    
 
 
 
 
 
 
(A photocopy of this authorization is to be accepted as an original.) 
 
SIGN
SIGN

TOWN OF WATERFORD 
  Equal Employment Opportunity Information 
Page 7 
 
 
 
OPTIONAL 
 
In  order  to  comply  with  certain  governmental  recordkeeping  and  reporting  requirements  for  the 
administration  of  civil  rights  laws,  applicants  are  invited  to  voluntarily  self‐identify  their  gender  and 
race/ethnicity.  Submission of this information is voluntary and refusal to provide it will not subject you 
to  any  adverse  treatment.    The  information  obtained  may  only  be  used  in  accordance  with  the 
provisions  of  applicable  laws,  executive  orders,  and  regulations,  including  those  that  require  the 
information to be summarized and reported to the federal government for civil rights enforcement. 
 
 
 
Gender: 
 Male 
 Female 
 
 
 
Ethnicity (check one): 
 
  Hispanic or Latino – a person of Cuban, Mexican, Puerto Rican, South or Central American, or other 
Spanish culture or origin, regardless of race. 
 
  Not Hispanic or Latino 
 
 
 
Race (check all that apply): 
 
  American Indian or Alaska Native – a person having origins in any of the original peoples of North 
or  South  America  (including  Central  America),  and  who  maintains  tribal  affiliation  or  community 
attachment. 
 
  Asian – a person having origins in any of the original peoples of the Far East, Southeast Asia, or the 
Indian  subcontinent,  including,  for  example,  Cambodia,  China,  India,  Japan,  Korea,  Malaysia, 
Pakistan, the Philippine Islands, Thailand, or Vietnam. 
 
  Black or African American – a person having origins in any of the black racial groups in Africa. 
 
  Native Hawaiian or Other Pacific Islander – a person having origins in any of the original peoples of 
Hawaii, Guam, Samoa, or other Pacific islands. 
 
  White – a person having origins in any of the original peoples of Europe, the Middle East, or North 
Africa. 
 

 
 
Page 8 
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la 
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552. 
 
A Summary of Your Rights Under the Fair Credit Reporting Act 
 
 
 
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and 
privacy of information in the files of consumer reporting agencies.  There are many types of 
consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies 
that sell information about check writing histories, medical records, and rental history records).  
Here is a summary of your major rights under FCRA.  For more information, including 
information about additional rights, go to www.consumerfinance.gov/learnmore or write 
to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552. 
 
 You must be told if information in your file has been used against you.  Anyone who 
uses a credit report or another type of consumer report to deny your application for credit, 
insurance, or employment – or to take another adverse action against you – must tell you, 
and must give you the name, address, and phone number of the agency that provided the 
information. 
 
 You have the right to know what is in your file.  You may request and obtain all the 
information about you in the files of a consumer reporting agency (your “file 
disclosure”).  You will be required to provide proper identification, which may include 
your Social Security number.  In many cases, the disclosure will be free.  You are entitled 
to a free file disclosure if: 
 
o a person has taken adverse action against you because of information in your 
credit report; 
o you are the victim of identity theft and place a fraud alert in your file; 
o your file contains inaccurate information as a result of fraud; 
o you are on public assistance; 
o you are unemployed but expect to apply for employment within 60 days. 
 
In addition, all consumers are entitled to one free disclosure every 12 months upon 
request from each nationwide credit bureau and from nationwide specialty consumer 
reporting agencies.  See www.consumerfinance.gov/learnmore for additional 
information. 
 
 You have the right to ask for a credit score.  Credit scores are numerical summaries of 
your credit-worthiness based on information from credit bureaus.  You may request a 
credit score from consumer reporting agencies that create scores or distribute scores used 
in residential real property loans, but you will have to pay for it.  In some mortgage 
transactions, you will receive credit score information for free from the mortgage lender. 
 
 You have the right to dispute incomplete or inaccurate information.  If you identify 
information in your file that is incomplete or inaccurate, and report it to the consumer 

 
 
Page 9 
reporting agency, the agency must investigate unless your dispute is frivolous.  See 
www.consumerfinance.gov/learnmore for an explanation of dispute procedures. 
 
 Consumer reporting agencies must correct or delete inaccurate, incomplete, or 
unverifiable information.  Inaccurate, incomplete, or unverifiable information must be 
removed or corrected, usually within 30 days.  However, a consumer reporting agency 
may continue to report information it has verified as accurate. 
 
 Consumer reporting agencies may not report outdated negative information.  In 
most cases, a consumer reporting agency may not report negative information that is 
more than seven years old, or bankruptcies that are more than 10 years old. 
 
 Access to your file is limited.  A consumer reporting agency may provide information 
about you only to people with a valid need – usually to consider an application with a 
creditor, insurer, employer, landlord, or other business.  The FCRA specifies those with a 
valid need for access. 
 
 You must give your consent for reports to be provided to employers.  A consumer 
reporting agency may not give out information about you to your employer, or a potential 
employer, without your written consent given to the employer.  Written consent generally 
is not required in the trucking industry.  For more information, go to 
www.consumerfinance.gov/learnmore. 
 
 You may limit “prescreened” offers of credit and insurance you get based on 
information in your credit report.  Unsolicited “prescreened” offers for credit and 
insurance must include a toll-free phone number you can call if you choose to remove 
your name and address form the lists these offers are based on.  You may opt out with the 
nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688). 
 
 The following FCRA right applies with respect to nationwide consumer reporting 
agencies: 
 
CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE 
 
You have a right to place a “security freeze” on your credit report, which will 
prohibit a consumer reporting agency from releasing information in your credit 
report without your express authorization.  The security freeze is designed to prevent 
credit, loans, and services from being approved in your name without your consent.  
However, you should be aware that using a security freeze to take control over who gets 
access to the personal and financial information in your credit report may delay, interfere 
with, or prohibit the timely approval of any subsequent request or application you make 
regarding a new loan, credit, mortgage, or any other account involving the extension of 
credit. 
 
As an alternative to a security freeze, you have the right to place an initial or extended 
fraud alert on your credit file at no cost.  An initial fraud alert is a 1-year alert that is 

 
 
Page 10 
placed on a consumer’s credit file.  Upon seeing a fraud alert display on a consumer’s 
credit file, a business is required to take steps to verify the consumer’s identity before 
extending new credit.  If you are a victim of identity theft, you are entitled to an extended 
fraud alert, which is a fraud alert lasting 7 years. 
 
A security freeze does not apply to a person or entity, or its affiliates, or collection 
agencies acting on behalf of the person or entity, with which you have an existing 
account that requests information in your credit report for the purposes of reviewing or 
collecting the account.  Reviewing the account includes activities related to account 
maintenance, monitoring, credit line increases, and account upgrades and enhancements. 
 
 You may seek damages from violators.  If a consumer reporting agency, or, in some 
cases, a user of consumer reports or a furnisher of information to a consumer reporting 
agency violates the FCRA, you may be able to sue in state or federal court. 
 
 Identity theft victims and active duty military personnel have additional rights.  For 
more information, visit www.consumerfinance.gov/learnmore. 
 
States may enforce the FCRA, and many states have their own consumer reporting laws.  
In some cases, you may have more rights under state law.  For more information, contact 
your state or local consumer protection agency or your state Attorney General.  For 
information about your federal rights, contact:  
 

 
 
Page 11 
TYPE OF BUSINESS: 
CONTACT: 
1.a. Banks, savings associations, and credit unions with total 
assets of over $10 billion and their affiliates 
 
 
b. Such affiliates that are not banks, savings associations, or 
credit unions also should list, in addition to the CFPB: 
a. Consumer Financial Protection Bureau 
1700 G Street, N.W. 
Washington, DC 20552 
 
b. Federal Trade Commission 
Consumer Response Center 
600 Pennsylvania Avenue, N.W. 
Washington, DC 20580 
(877) 382-4357 
2. To the extent not included in item 1 above: 
a. National banks, federal savings associations, and federal 
branches and federal agencies of foreign banks 
 
 
b. State member banks, branches and agencies of foreign banks 
(other than federal branches, federal agencies, and Insured State 
Branches of Foreign Banks), commercial lending companies 
owned or controlled by foreign banks, and organizations 
operating under section 25 or 25A of the Federal Reserve Act. 
 
c. Nonmember Insured Banks, Insured State Branches of 
Foreign Banks, and insured state savings associations 
 
d. Federal Credit Unions 
a. Office of the Comptroller of the Currency 
Customer Assistance Group 
1301 McKinney Street, Suite 3450 
Houston, TX 77010-9050 
 
b. Federal Reserve Consumer Help Center 
P.O. Box 1200 
Minneapolis, MN 55480 
 
 
c. FDIC Consumer Response Center 
1100 Walnut Street, Box #11 
Kansas City, MO 64106 
 
d. National Credit Union Administration 
Office of Consumer Financial Protection (OCFP) 
Division of Consumer Compliance Policy and Outreach 
1775 Duke Street 
Alexandria, VA 22314 
3. Air carriers 
Asst. General Counsel for Aviation Enforcement & Proceedings 
Aviation Consumer Protection Division 
Department of Transportation 
1200 New Jersey Avenue, S.E. 
Washington, DC 20590 
4. Creditors Subject to the Surface Transportation Board 
Office of Proceedings, Surface Transportation Board 
Department of Transportation 
395 E Street, S.W. 
Washington, DC 20423 
5. Creditors Subject to the Packers and Stockyards Act, 1921 
Nearest Packers and Stockyards Administration area supervisor 
6. Small Business Investment Companies 
Associate Deputy Administrator for Capital Access 
United States Small Business Administration 
409 Third Street, S.W., Suite 8200 
Washington, DC 20416 
7. Brokers and Dealers 
Securities and Exchange Commission 
100 F Street, N.E. 
Washington, DC 20549 
8. Federal Land Banks, Federal Land Bank Associations, 
Federal Intermediate Credit Banks, and Production Credit 
Associations 
Farm Credit Administration 
1501 Farm Credit Drive 
McLean, VA 22102-5090 
9. Retailers, Finance Companies, and All Other Creditors Not 
Listed Above 
Federal Trade Commission 
Consumer Response Center 
600 Pennsylvania Avenue, N.W. 
Washington, DC 20580 
(877) 382-4357