Revised 3/2019
APPLICATION FOR EMPLOYMENT
WITH
SANDUSKY COUNTY LAND
REUTILIZATION CORPORATION
INSTRUCTIONS: Please fill out this employment application form completely and accurately. Print or type in
a legible manner. Failure to complete certain portions of this form may result in disqualification.
LAST NAME FIRST NAME MIDDLE INITIAL
STREET ADDRESS ________________________________ CITY
STATE ZIP CODE COUNTY
HOME PHONE #__________________________ EMAIL ADDRESS
CELL PHONE # __________________________ SOCIAL SECURITY NUMBER
APPLICATIONS ARE FILED ACCORDING TO SPECIFIC JOB OPPORTUNITIES POSTED. WE DO NOT ACCEPT
OR MAINTAIN ON FILE UNSOLICITED APPLICATIONS.
Date of Application:
Specify the name of the advertised position(s) you are applying for:
What is your minimum salary requirement?
What is the earliest date you will be able to accept employment / volunteer?
Do you meet the minimum qualifications and can you perform the job duties related to the specific job for
which you are applying? Yes No
Do you have any commitments to anyone, which might affect immediate employment with this
organization? Yes No
If yes, explain:
FOR OFFICIAL USE ONLY
High School Attended _______________________________________________________________________
Address ___________________________________________________________________________________
Did you graduate? Yes No High school equivalent? Yes No
College or trade school attended
Address
Dates of Attendance to
Did you graduate? Yes No Degree ___
Graduate school attended
Address
Dates of Attendance to
Did you graduate? Yes No Degree ___
Please describe any coursework or technical training you have received which will better enable you to perform the
job for which you are applying. Include any licenses or certification you have obtained that will relate to your work.
If you have received any other training, not mentioned above, please describe. Include any equipment or
instruments you can operate, any foreign language skills, or any other skills you possess which better indicate
your ability to perform the job for which you are applying.
EMPLOYMENT HISTORY
Please describe your employment history (Including military service). Begin with your most recent or present employer.
Present or most recent job:
1. Company / Employer’s Name: Address:
City/State/Zip code: Phone:
Supervisor or Personnel Director’s Name:
Dates Employed: Start: End: Salary / Rate of Pay:
Describe your reason for leaving:
Job Title or Position:
Describe your duties and responsibilities, equipment operated, instruments used, etc.
2. Company / Employer’s Name: Address:
City/State/Zip code: Phone:
Supervisor or Personnel Director’s Name:
Dates Employed: Start: End: Salary / Rate of Pay:
Describe your reason for leaving:
Job Title or Position:
Describe your duties and responsibilities, equipment operated, instruments used, etc.
3. Company / Employer’s Name: Address:
City/State/Zip code: Phone:
Supervisor or Personnel Director’s Name:
Dates Employed: Start: End: Salary / Rate of Pay:
Describe your reason for leaving:
Job Title or Position:
Describe your duties and responsibilities, equipment operated, instruments used, etc.
TO BE COMPLETED BY APPLICANT
I do hereby give permission to the Sandusky County Land Reutilization Corporation to seek information concerning
any employment experience. I have been employed by the employers listed on my job application and give the
following permission to release any job related information requested by Sandusky County Land Reutilization
Corporation in order to determine whether I am suited for employment by them.
EMPLOYERS AUTHORIZED TO RELEASE INFORMATION
1.
2.
3.
I understand the Sandusky County Land Reutilization Corporation will verify information obtained from my job
application, resume and other related documents. It is my understanding that Sandusky County Land Reutilization
Corporation may make a thorough investigation of my entire employment history and I release from liability any
person giving or receiving any such lawful information.
I have read and understand the authorization granted above and agree to the same as a condition of my prospective
employment.
Applicant's Signature: Date:
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signature
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APPLICANT BACKGROUND INVESTIGATION
Certain positions with Sandusky County Land Reutilization Corporation require that an individuals past history be
investigated to determine whether the person can qualify for consideration for appointment. Therefore, prior to
appointment to these positions with the Sandusky County Land Reutilization Corporation, individuals selected for
hire will undergo a background check with a local law-enforcement agency. Failure to complete this waiver will
result in disqualification for employment with Sandusky County Land Reutilization Corporation.
I authorize release of any police record information in my name, to the Sandusky County Sandusky County Land
Reutilization Corporation.
Name: ____________________________________________________________________
(Please print) Last Middle First
List any other NAMES you have used during the previous five (5) years:
Please Print
List any COUNTIES AND STATES in which you have lived and/or worked during the previous five (5) years:
Please Print
Social Security Number:
Signature:
REPORT
OFFICIAL:
DATE:
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signature
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REQUEST FOR MOTOR VEHICLE RECORD CHECK
In accordance with the provisions of Section 604 and Section 607 of the Fair
Credit Reporting Act, Public Law 91-508, I hereby certify that the information
requested below will be used for a “permissible purpose” as defined in the Act, and
that the information received will be used for no other purpose.
I further certify that if the applicant named below is denied employment based
upon the information received, I will identify the source of the report in accordance
with Section 615 (a) of the Fair Credit Reporting Act.
REQUESTED BY: Sandusky County Land Reutilization Corporation
To Whom It May Concern:
The following has made an application with Sandusky County Land Reutilization
Corporation. In accordance with Section 391.23. of the Federal Department of
Transportation Regulations, please furnish the above signed with the applicants
driving record for the last three (3) years.
Name of Applicant: ______________________________________________
Address: ______________________________________________________
City/State/Zip: _________________________________________________
Social Security Number: _________________________________________
Driver’s License Number: ________________________________________
State License Issued In: __________________________________________
Signature of Applicant: __________________________________________
I GRANT PERMISSION TO SANDUSKY COUNTY LAND REUTILIZATION CORPORATION TO RECEIVE INFORMATION REGARDING
MY DRIVING RECORD
.
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signature
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REFERENCES: Please list the name and address of three individuals, other than relatives, whom we may contact for a
professional reference:
1. Name Address
City/State Telephone
2. Name Address
City/State Telephone
3. Name Address
City/State Telephone
SANDUSKY COUNTY LAND REUTILIATION CORPORATION is an equal opportunity employer and selects the best
matched individual for any job based upon job related qualifications, regardless of race, color, creed, sex, national origin,
age, handicap or other protected groups under state, federal or local Equal Opportunity Laws.
1) I understand and accept that if any information required in this application (and attached resume, if any) is
found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I
further understand and accept that, if I am employed by the Employer, I may be subject to disciplinary action,
including termination, if any information required by this application has been falsified or intentionally
excluded.
Initials:
2) I understand and accept that Sandusky County Land Reutilization Corporation will make a thorough investigation
of my entire work history and may verify all data given on my application for employment, related papers, or oral
interviews. I authorize such investigation and the giving and receiving of any information requested by Sandusky
County and I release from liability any person giving or receiving any such lawful information. I understand the
falsification of data so given or other derogatory information discovered as a result of this investigation may
prevent my being hired.
Initials:
3) I understand and accept If offered a position, I agree to authorize my physician or hospital to release any
information which may be necessary to determine my ability to perform the essential functions of a job for which
am being considered, prior to employment or in the future during my employment with Sandusky County Land
Reutilization Corporation.
Initials:
4) I understand and accept, although management makes every effort to accommodate individual preferences,
business needs may at times make the following conditions mandatory; overtime, shift work, a rotating work
schedule, or work schedule other than Monday through Friday. I understand and accept these as conditions of
my continuing employment.
Initials:
**READ CAREFULLY BEFORE SIGNING**
I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THIS EMPLOYMENT
APPLICATION IS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I
AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I
UNDERSTAND THAT ANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATION
PROVIDED MAY LEAD TO WITHDRAWAL OF AN EMPLOYMENT OFFER OR TERMINATION
FOLLOWING EMPLOYMENT. I RECOGNIZE THAT MY FUTURE EMPLOYMENT WITH THE
EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE,
OR ALCOHOL ABUSE.
Applicant's Signature Date
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signature
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