Fillable 5470 PAPER APPLICATION (Harford County Government)

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5470 PAPER APPLICATION (Harford County Government)

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BROWSE HARFORD COUNTY GOVERNMENT (MD) FORMS

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APPLICATION FOR EMPLOYMENT
HARFORD COUNTY GOVERNMENT
DEPARTMENT OF HUMAN RESOURCES
220 SOUTH MAIN STREET
BEL AIR, MARYLAND 21014
www.harfordcountymd.gov ~ OFFICE: 410-638-3201 ~ FAX: 410-879-3564
(THIS APPLICATION MUST BE TYPED OR PRINTED IN INK – ATTACH ADDITIONAL SHEETS IF NECESSARY)
VACANY NO:
TITLE:
CLOSING DATE:
SOCIAL SEC. #:
PRESENT ADDRESS:
TELEPHONE NO:
DRIVER’S LIC. NO:
STATE:
CLASS:
EXPIRES:
IS THIS A CDL DRIVER’S LICENSE?:
YES
NO
IF YES, PLEASE LIST ALL ENDORSEMENTS:
PLEASE LIST ANY LEARNER’S PERMITS THAT YOU POSSESS:
IS YOUR DRIVER’S LICENSE SUSPENDED?:
YES
NO
HAVE YOU EVER BEEN CONVICTED OF A FELONY?:
YES
NO
IF YES, PLEASE GIVE NATURE OF CRIME(S), YEAR(S) OF CONVICTIONS:
DATE OF BIRTH: (LAW ENFORCEMENT, CORRECTIONS, & PUBLIC SAFETY DISPATCHER APPLICATIONS ONLY)
EDUCATION: ARE YOU A HIGH SCHOOL GRADUATE?
YES
NO
NAME OF HIGH SCHOOL:
HIGH SCHOOL EQUIV. CERT. OR GED# OR STATE WHICH GRANTED CERTIFICATE:
LIST ANY PROFESSIONAL/TECHNICAL LICENSES, THE AUTHORIZAING STATE AND DATE OF EXPIRATION:
LIST COLLEGE, TECHNICAL SCHOOL, OR OTHER ADVANCED TRAINING
NAME
FROM
(MO/YR)
TO
(MO/YR)
DEGREE (BA, BS, MA & MAJOR)
MILITARY SERVICE: BRANCH
TYPE OF DISCHARGE:
YRS SERVED: FROM
TO:
RANK AT DISCHARGE:
PRIMARY & SECONDARY MOS:
ARE YOU CLAIMING VETERANS PREFERENCE?:
YES
NO
IF YES, YOU MUST ATTACH A COPY OF ONE OF THE FOLLOWING YOUR CERTIFICATE OF HONORABLE DISCHARGE,
CERTIFICATE OF SATISFACTORY COMPLETION OF MILITARY SERVICE OR VA CERTIFICATE TO THE APPLICATION AT THE
TIME OF SUBMITTAL.
HARFORD COUNTY IS AN EQUAL OPPORTUNITY AFFIRMATIVE ACTION EMPLOYER
IF MAILING APPLICATION WITH RESUME, BE SURE TO AFFIX ADEQUATE POSTAGE TO ENSURE DELIVERY. BE ADVISED THAT TO BE CONSIDERED
FOR THE POSITION YOU ARE APPLYING FOR YOUR APPLICATION AND ANY ACCOMPANYING DOCUMENTATION MUST BE RECEIVED BY THE
CLOSING DATE. APPLICATIONS AND ACCOMPANYING DOCUMENTATION RECEIVED AFTER THE CLOSING DATE WILL NOT BE ACCEPTED.
EMPLOYMENT HISTORY
INSTRUCTIONS: PLEASE READ THESE INSTRUCTIONS CAREFULLY, IN ORDER TO BE CONSIDERED FOR EMPLOYMENT,
ALL INFORMATION MUST BE COMPLETED ACCURATELY. IF YOU HAVE QUESTIONS, PLEASE CALL THE DEPARTMENT OF
HUMAN RESOURCES FOR HELP.
1. LIST YOUR PRESNT AND PAST EMPLOYERS, STARTING WITH THE CURRENT EMPLOYER FIRST.
2. IF YOU ARE A CURRENT COUNTY EMPLOYEE, PLEASE INDICATE THAT THE COUNTY IS YOUR CURRENT
EMPLOYER AND PROVIDE THE DETAILS OF YOUR JOB AS ASKED.
3. PROVIDE THE NAME(S) OF YOUR IMMEDIATE SUPERVISOR(S) IN YOUR PAST AND CURRENT POSITIONS.
4. LIST THE NAME, ADDRESS, AND PHONE NUMBER OF ALL YOUR PAST AND CURRENT EMPLOYERS (USE
ADDITIONAL PAPER IF NECESSARY).
5. LIST ACCURATE MONTHS/DATES OF EMPLOYMENT FOR EACH PAST AND CURRENT EMPLOYER.
6. ATTACH ADDITIONAL SHEETS IF NECESSARY.
EMPLOYER NAME:
ADDRESS:
STREET CITY STATE ZIP
TELEPHONE #:
NAME & TITLE OF SUPERVISOR:
SALARY:
EMPLOYED FROM:
TO:
MONTH/YR
MONTH/YR
JOB TITLE & DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER FOR REFERENCES?:
YES
NO
EMPLOYER NAME:
ADDRESS:
STREET CITY STATE ZIP
TELEPHONE #:
NAME & TITLE OF SUPERVISOR:
SALARY:
EMPLOYED FROM:
TO:
MONTH/YR
MONTH/YR
JOB TITLE & DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER FOR REFERENCES?:
YES
NO
EMPLOYER NAME:
ADDRESS:
STREET CITY STATE ZIP
TELEPHONE #:
NAME & TITLE OF SUPERVISOR:
SALARY:
EMPLOYED FROM:
TO:
MONTH/YR
MONTH/YR
JOB TITLE & DUTIES:
REASON FOR LEAVING:
MAY WE CONTACT THIS EMPLOYER FOR REFERENCES?:
YES
NO
DESCRIBE ANY SIGNIFICANT VOLUNTEER WORK, WHICH MAY BE USED TO QUALIFY YOU FOR THE POSITION FOR WHICH
YOU ARE APPLYING, LIST DATES AND PERSON TO CONTACT FOR REFERENCES.
LIST BELOW ANYY ADDITIONAL INFORMATION YOU CONSIDER PERTINENT TO YOUR APPLICATION FOR EMPLOYMETN
INCLUDING SPECIAL SKILLS SUCH AS OPERATION OF OFFICE EQUIPMENT, VEHICULAR EQUIPMENT, COMPUTERS, ETC.
PLEASE INDICATE THE SOURCE FROM WHICH YOU LEARNED OF THIS POSITION:
NEWSPAPER (NAME)
COUNTY EMPLOYEE
BULLETIN BOARD (POSTED WHERE)
OTHER (SPECIFY)
INTERNET
LIST THREE PERSONAL REFERENCES (NOT RELATED TO YOU)
TELEPHONE #:
ADDRESS:
TELEPHONE #:
ADDRESS:
TELEPHONE #:
ADDRESS:
DO YOU HAVE ANY RELATIVES EMPLOYED WITH HARFORD COUNTY GOVERNMENT?:
YES
NO
IF YES, STATE NAME, RELATIONSHIP AND EMPLOYEES WORK LOCATION:
HAVE YOU PREVIOSULY BEEN EMPLOYED BY HARFORD COUNTY GOVERNMENT? IF SO, PLEASE PROVIDE THE DATES
AND DEPARTMENT.
ARE YOU CURRENTLY AN EMPLOYEE OF HARFORD COUNTY GOVERNMENT?:
YES
NO
HAVE YOU PARTICIPATED IN HARFORD COUNTY GOVERNMENT’S TRAINING PROGRAM?:
YES
NO
IF YES, PLEASE PROVIDE THE TITLE OF THE TRAINING CLASSES YOU HAVE TAKEN:
IF YOU ARE CURRENTLY A HARFORD COUNTY GOVERNMENT EMPLOYEE, PLEASE COMPLETE THE FOLLOWING
SECTION.
HAVE YOU BEEN COMPENSATED FOR WORKING OUT OF CLASSIFICATION IN THE POSITION
TITEL FOR WHICH YOU ARE SUBMITTING THIS APPLICATION?
YES
NO
IF YES, PLEASE PROVIDE DATE(S) YOU WERE COMPENSATED:
APPLICATION INFORMATION
THE FOLLOWING INFORMATION IS VOLUNTARY:
THE INFORMATION BELOW IS REQUESTED TO MEET THE REQUIREMENTS OF CERTAIN FEDERAL AGENCIES AND WILL BE
SEEN AND TABULATED BY THE DEPARTMENT OF HUMAN RESOURCES ONLY. IT IS CONFIDENTIAL INFORMATION AND
WILL NOT BE USED IN ANY EMPLOYMENT DECISION.
POSITION APPLIED FOR:
(JOB TITLE AS LISTED ON FRONT OF APPLICATION)
SEX:
MALE
FEMALE
DATE OF BIRTH:
RACE/ETHNIC INFORMATION: CHECK ONE ONLY
WHITE – NOT OF HISPANIC ORIGIN – A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF EUROPE,
NORTH AFRICA OR THE MIDDLE EAST.
BLACK – NOT OF HISPANIC ORIGIN – A PERSON HAVING ORIGINS IN ANY OF THE BLACK RACIAL GROUPS OF
AFRICA.
HISPANIC – A PERSON OF PUERTO RICO, MEXICAN, CUBAN, CENTRAL OR SOUTH AMERICAN OR OTHER SPANISH
CULTURE OR ORIGIN, REGARDLESS OF RACE.
ASIAN OR PACIFIC ISLANDER – A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF THE FAR EAST,
SOUTHEAST ASIA, THE INDIAN SUBCONTINENT, OR THE PACIFIC ISLANDS. EXAMPLES: CHINA, JAPAN, KOREA, THE
PHILLIPPINES, SAMOA.
AMERICAN INDIAN OR ALASKAN NATIVE – A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF
NORTH AMERICA AND WHO MAINTAINS TRIBAL AFFILIATION OR COMMUNITY RECOGNITION.
PLEASE BE SURE ALL PAGES HAVE BEEN COMPLETED
CANDIDATE SELECTED FOR POSITION MUST PERFORM ESSENTIAL JOB FUNCTIONS WITH OR WITHOUT REASONABLE
ACCOMODATION AND MUST UNDERGO AND PASS A COUNTY PRE-EMPLOYMENT MEDICAL EXAM TO INCLUDE URINE
DRUG SCREENING.
APPLICATIONS FOR ANY POSITION REQUIRING A COMMERICAL DRIVER’S LICENSE WILL BE REQUIRED, AS A CONDITION
OF EMPLOYMENT, TO SIGN A RELEASE AUTHORIZING HARFORD COUNTY GOVERNMENT TO OBTAIN ALCOHOL AND
CONTROLLED SUBSTANCE USE AND/OR TEST RECORDS FROM PREVIOUS EMPLOYERS.
SIGNATURE IS REQUIRED FOR THE FOLLOWING AUTHORIZATIONS AND ACKNOWLEDGEMENT OF INFORMATION:
Please READ carefully before signing: If you have used any other name in previous employment, please provide us with the name used at
your prior place of employment. PRINT OR TYPE YOUR NAME AS WELL AS SIGNING YOUR LEGAL SIGNATURE.
I AUTHORIZE THE HARFORD COUNTY DEPARTMENT OF HUMAN RESOURCES TO INVESTIGATE ANY AND ALL STATEMENTS
MADE ON THIS APPLICATION, INCLUDING ANY DRIVING RECORD. SUCH AUTHORIZATION INCLUDES OBTAINING RECORDS
FROM PAGE EMPLOYERS, EDUCATIONAL TRANSCRIPTS, LAW ENFORCEMENT AGENCIES AND/OR CREDIT REPORTING
SERVICES. I ALSO AUTHORIZE HARFORD COUNTY TO PERFORM A CRIMINAL BACKGROUND CHECK INCLUDING, BUT NOT
LIMITED TO, FINGERPRINTING AND CRIMINAL RECORD REVIEW. IF ANY MISREPRESENTATION HAS BEEN MADE OR IF THE
RESULTS OF THE INVESTIGATION ARE UNSATISFACTORY, ANY OFFER OF EMPLOYMENT MAY BE WITHDRAWN; IN THE
EVENT THAT I AM ALREADY EMPLOYED BY HARFORD COUNTY, MY EMPLOYMENT MAY BE TERMINATED.
The following notice applies to everyone excepts applicants for law enforcement officer positions as defined by Section 3-101 of
the Public Safety Article of the Annotated Code of Maryland:
UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT,
PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR
OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT
EXCEEDING $100.00.
MAKE SURE YOU HAVE COMPLETED ALL APPLICABLE SECTIONS ON THIS APPLICATION FORM AND HAVE SIGNED BELOW.
THIS APPLICATION WILL NOT BE CONSIDERED IF YOU HAVE NOT FILLED IT OUT COMPLETELY, OR HAVE NOT SIGNED IT.
PRINTED/TYPED FULL NAME:
SOCIAL SECURITY #:
PRINTED/TYPED FULL NAME USED AT PRIOR EMPLOYMENT:
SIGNATURE:
DATE:
LIST A TELEPHONE NUMBER WHERE YOU CAN BE REACHED TO SCHEDULE AND INTERVIEW AND WHAT HOURS ARE
BEST TO CALL THIS NUMBER:____________________________________________________________________________
HARFORD COUNTY GOVERNMENT IS A DRUG FREE WORKPLACE/SMOKE FREE ENVIRONMENT
HARFORD COUNTY
MARYLAND’S NEW CENTER FOR OPPORTUNITY
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5470 PAPER APPLICATION (Harford County Government)

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Completed 13 February 2021

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