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202 N. State Route 89
Chino Valley, AZ 86323
(928) 636-2646 Office
(928) 636-9129 Fax
It is the policy of the Town of Chino Valley to provide equal opportunity employment. Selection and employment of applicants shall be made on the basis of qualifications without regard to age, disability, national origin, race, color, sex or religion. If hired, you will be required to furnish proof of your eligibility to work in the United States.
Please answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discriminations based upon non job-related information.
The following information must be completed and submitted with the application.
The term “background investigation” as used in this document refers to any and all information and sources of information that the Town of Chino Valley, Arizona (“Town”), in it sole discretion, may deem necessary to obtain or contact, to
determine my fitness as a candidate for employment with the Town.
1. In accordance with the Town Personnel Policy and Administrative Guideline Manual Policies #200 and #205, all
prospective employees of the Town are required to submit fingerprints to Human Resources for the purpose of obtaining a state and national criminal history records check by the Federal Bureau of Investigation, except prospective temporary and part-time employees who shall be employed less than ninety (90) days, unless such
position requires working with children under eighteen (18) years of age.
2. I authorize any person or entity contacted by the Town’s officers, agents, and employees during the course of my
background investigation, to furnish to such officers, agents, and employees any information or opinions they may have.
3. I hereby release from liability and hold harmless the Town and its agents, officers and employees for, from and
against, any and all causes of action, claims, demands, suits, damages, costs, and debts, both in law and in equity which I may have, or in the future may have, of any nature whatsoever, including any and all claims arising from any statements, acts or omissions, or any information or opinions furnished to the employees of the Town as
part of my background investigation.
4. I expressly agree that I will not, under any circumstances, attempt to obtain the results of my background investigation as conducted by the Town, realizing that such information must, of necessity, remain confidential.
The town is committed to a drug-free workplace to protect the safety of workers and the public. It is the policy of the Town
that applicants take a drug screen to show they are drug free.
1. In consideration for my being considered for employment by the Town, I give my consent to, and authorize, any
Town designated collection site to perform any testing on my urine to determine the presence and/or level of any
drug designated by the Town.
2. I give my consent for the release without restriction to the Town, of my individually identifiable health information
or other medical records related to any medical tests. This release authority applies to any information governed
by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). All physicians, employees, and
agents who work or perform services for any Town designated collection site are held harmless from any action that may arise out of such test results being disclosed to the Town.
3. I understand and acknowledge that any of the following will constitute a violation of the drug policy for the Town:
1. Refusal to sign this or any related form. 2. Failure to appear to be tested. 3. Leaving the collection site for any
reason prior to providing a sample. 4. The adulteration of any sample. 5. A positive test result
4. I understand and acknowledge that if I am employed by the Town, I am subject to the policies and procedures set
forth in the Town of Chino Valley Personnel Policy and Administrative Guideline Manual, including, but not limited
to, the policies regarding Drug and Alcohol Free Workplace and Testing.
In consideration of the Town processing my application for employment, I irrevocably agree to the above terms and
conditions, and affirm that I have read and understand the meaning of the above statement of policy. This release
from liability given by me to the Town and its employees, and all others as mentioned previously shall apply to any
right of action of any nature whatsoever that might accrue to me, my heirs, my personal representatives, successors
and assigns. I acknowledge that failure to pass the background investigation, a violation of the drug policy of the
Town, or any other above stated conditions of employment will render me ineligible for employment with the Town for
a minimum of one (1) year. Further, any prior conditional offer of employment will be withdrawn. I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.
I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release and hold harmless such persons and organizations from any legal liability in making such statements.
I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME.
I have read, understand, and by my signature consent to these statements.
*If under 18, parent or guardian signature is required. I understand this authorization is valid for a period of two (2) years.
The Town of Chino Valley conducts an extensive background investigation of criminal history. Please be very careful in completing this section. Human Resources will verify this information. A criminal record may not disqualify an individual
from employment consideration of retention; however, FAILURE TO DISCLOSE ALL INFORMATION REQUESTED ON
THIS FORM, will result in disqualification for employment with the Town of Chino Valley. For EACH OFFENSE, include
month/year/location and complete disposition. For any conviction resulting in incarceration, provide dates and name of institutions.
Traffic violations are included in the background results obtained through the criminal records check. If a good driving
record is applicable to the position for which you applied, the results may negatively impact your employment with the
Town of Chino Valley.
I understand that should I fail to disclose all information requested in this form regarding convictions, my application will
not receive further consideration and I will not be considered for employment for a minimum of one year. The complete
results of the fingerprint criminal records check may not be available for two months or more. I further understand that if I
obtain employment with the Town of Chino Valley and information is received regarding the conviction, which should have
been disclosed on this form, but was not, I may be dismissed from employment with the Town.
The Town of Chino Valley is an equal opportunity employer. The following information is voluntary and necessary for statistical government record keeping and reporting purposes. This data is confidential and will NOT be included in your application. If will be separately retained and it will have NO bearing upon the process of considering you for employment.
This field is not part of the form submission.
* indicates a required field