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I hereby authorize my physician, - City of Providence

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ISSUE DATE (MMDDYY)

City of Providence Job Application

Information For Internal Purposes

CITY OF PROVIDENCE DEPARTMENT OF HUMAN RESOURCES APPLICATION FOR EMPLOYMENT Personal Information Name (Last, First, Middle) Address (Street) Address (City, State, Zip Code) Home Telephone Mobile Telephone Position Applying For: Have you filed an appl

Professional Organizations/Licenses

Providence previously

325 Washington Street

Providence or any of it's agencies boards or

A CONCEALED PISTOL OR REVOLVER

Are you currently receiving, or will become

eligible in the future to receive a pension from

either the City of Providence or the Providence

If yes, are you willing to waive your right to

receive such pension or part of such pension

during this new employment with the City of

(Section 17-8, Code of Ordinances)

Are you over 18 years of age

Date of availability

Are you currently under contract with another

of the job for which you are applying with or

without reasonable accommodations

I hereby authorize my physician,

If offered a position, the Immigration Reform and Control

Act of 1986 requires you to furnish proof of your

Employment Eligibility and your identity

List all languages in which you are fluent

Have you ever been dismissed or asked to

resign, from any position

Have you ever worked for the City of Providence or any of it's agencies boards or commissions

List any job-related organizations of which you are a member andor list any and all professional licenses you may hold along with

license number and expiration date