Design Date: 7/19/2010; Revised Date 01/03/2014
RECORD OF EMPLOYMENT (continued):
Employer: _____________________________________________________ Telephone: ____________________________
Position Title: ___________________________________________Supervisor: ___________________________________
Start Date:______________ Date Left:__________________ Beginning Salary: _______________ Ending Salary: _______
Reason for Leaving: ___________________________________________________________________________________
Employer: ______________________________________________________Telephone: ____________________________
Position Title:________________________________________ Supervisor: _______________________________________
Start Date:______________ Date Left:__________________ Beginning Salary: _______________ Ending Salary: ________
Reason for Leaving: ____________________________________________________________________________________
Note to Applicant: DO NOT ANSWER THE FOLLOWING QUESTION(S) UNLESS YOU HAVE BEEN INFORMED ABOUT
THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.
Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job
or occupation for which you have applied? Yes No
A copy of the job description or occupation has been given? Yes No
WORK-RELATED REFERENCES: (Do not include relatives)
Name Occupation Years Known Contact Information
1. _________________ ______________________ ___________ _____________________________________
2. _________________ ______________________ ___________ _____________________________________
3. _________________ ______________________ __________ _____________________________________
STATEMENT (Please read this statement carefully before signing this application):
I understand that employment with Buchanan County is at-will, meaning that the County or I may terminate my employment at any
time, or for any reason consistent with applicable state or federal law.
I authorize the County to conduct a thorough background investigation of my work and personal history, and verify all data given on
this application and during interviews. I hereby release the County, and its representatives or agents, from any liability that might
result from such an investigation. I authorize all individuals, schools, and firms named to provide any requested information and
release them from all liability for providing the requested information.
I understand that any offer of employment with the County will be contingent on passing a job-related physical examination, and/or
successful completion of a drug and/or alcohol test as a condition of employment.
I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States,
and that federal immigration laws require me to complete an I-9 Form in this regard.
Have you ever been known by any other name(s) that the county will require to verify any of the information on this application?
I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for
employment, I must submit a new application. I certify that all the statements in this completed application are true
understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.
Signature of Applicant: _______________________________________ Date Signed: ________________________________
DATE APPLICATION RECEIVED: _______________________ TIME RECEIVED: _____________ A.M./P.M.
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