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INSTRUCTIONS TO APPLICANT: Complete all pages of this application, either by typing or printing legibly. Please sign the last page. The application and any attachments become the property of the City of Nixa.

Answers of “yes” or “no” to questions 9-12 do not automatically disqualify you from employment.

LIST ALL POSITIONS you have held starting with the most recent. If same employer, list different titles each as separate employment. Employment history includes positions held, lapse of employment, and military duty. Use a blank sheet of paper if more room is needed. DO NOT indicate “See Resume.” A resume may be attached to provide supporting information, but will not be accepted in lieu of completing this section.

Employed (month and year)

Employed (month and year)

Employed (month and year)

Employed (month and year)

Employed (month and year)

Employed (month and year)

If a license, certificate, or other authorization to practice a trade or profession is required for the position for which you are applying, complete the following questions.

PLEASE READ CAREFULLY APPLICANT’S CERTIFICATION AND AGREEMENT I hereby certify that the facts set forth in the above employment application are true and correct to the best of my knowledge. They are made voluntarily upon application of employment, and as inducement, therefore, I understand that any false statement or information given herein shall be considered sufficient cause for dismissal. I, the undersigned, do hereby authorize the City of Nixa to conduct an investigation with respect to my application and release the City, my former employers and personal references from any liability for damage caused by giving and receiving information or opinions as to my employment or character. Any examining doctors, hospitals (public, private, state and including the United States Veterans Administration), may give the City of Nixa any information or data as the result of any examinations made. I agree to hold the City harmless and in no event shall the City be liable to me for special, indirect, or consequential damages, for the refusal of employment due to information obtained during my background security check. I understand and agree that the City of Nixa is under no obligation to reveal to me or any other person the reason for my rejection for employ- ment. I understand that I must physically reapply for employment if I wish to be considered for any other position open at the City of Nixa. I understand and agree with the City’s drug free workplace and that my employment with the City is contingent upon the drug test results.