Employment Application

Complete online or print and fill out by hand.

This application includes a Social Security Number field required for employment eligibility verification. Nothing entered here is transmitted or saved online — please print the completed form and deliver it to City Hall in person or by mail.

City of Lenox

Employment Application

Applicant Information

Last Name

First Name

M.I.

Street Address

Apartment/Unit #

City

State

ZIP

Phone

E-mail Address

Date Available

Social Security No.

Only entered on the printed copy you deliver in person — never transmitted online.

Desired Salary

Position Applied For

Eligibility Questions

Qualifications

Education

High School

Address

From

To

Graduated?

Yes No

Degree

College

Address

From

To

Graduated?

Yes No

Degree

Other

Address

From

To

Graduated?

Yes No

Degree

References

Please list three professional references.

Reference 1

Full Name

Relationship

Company

Phone

Address

Reference 2

Full Name

Relationship

Company

Phone

Address

Reference 3

Full Name

Relationship

Company

Phone

Previous Employment

Previous Employer 1

Company

Phone

Address

Supervisor

Job Title

Starting Salary ($)

Ending Salary ($)

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Previous Employer 2

Company

Phone

Address

Supervisor

Job Title

Starting Salary ($)

Ending Salary ($)

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature If printing to sign by hand, you may leave this field blank.

Date

Completed applications can be mailed to Lenox City Hall at 200 South Main Street, Lenox, Iowa 50851, or delivered in person.

This form is not submitted online. Please print and deliver the completed application to Lenox City Hall in person or by mail — this protects your Social Security Number and other sensitive information from being transmitted electronically.