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Returning Employee Form

  1. Name change since last employment with the city?*

  2. Returning Employment*

  3. Address change since last employment with the city?*

  4. Date of Birth

  5. Please use Format (111)123-1234

  6. Please use Format (111)123-1234

  7. Please use Format (111)123-1234

  8. Please use Format (111)123-1234

  9. Describe any instructions for emergency personnel - e.g., medical allergies, medical conditions etc. This info will be kept in the strictest confidence only to be used by the City in case of emergency and in no way affect your employment status.

  10. Direct Deposit Information *

  11. Please notify the exemption number you are using for your federal taxes

  12. Please notify the exemption number you are using for your federal taxes

  13. Direct Deposit (Optional)*

    Any banking account information changes since last employment with the City or new to participating? If yes, print form and submit to HR.

  14. Health Insurance Marketplace*

    I have read and understand the Exchange Notice and Eligibility Guidelines.

  15. City of Mayfield Heights Employee Handbook (Updated 4/2017)*

    I have read and understand the Employee Handbook set forth by the City of Mayfield Heights.

  16. Background Check

    For those employees 18 years and older, please review the section and state that all the info provided is correct. I authorize and give consent for the City of Mayfield Heights to obtain information regarding myself. This includes: Local and National Criminal background records/information, All 50 Sex Offender Registry checks, Address trace, and Information Verification. I authorize this information to be obtained either in writing or via telephone in connection with my volunteer application. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information is held in confidence in accordance with the organization's guidelines.

  17. Agreement*

  18. Drug Screening*

    I acknowledge that I have been informed that the City may engage in mandatory drug testing of applicants for positions, that I support such testing, and that I voluntarily consent to such testing.

  19. Testing Date

    For those employees 18 years and older, Pre-Employment Drug Screening has been scheduled for May 16, 2017, at 4:00 pm at city hall. Those unable to attend on that date must appear for testing at a center designated by the City prior to the commencement of employment. Contact HR for center locations and an authorization form if you will not attend testing at city hall.

  20. Leave This Blank:

  21. This field is not part of the form submission.