ARE YOU RELATED TO A MIDDLESEX COUNTY FREEHOLDER, COUNTY CLERK, SHERRIFF, SURROGATE,
DEPARTMENT HEAD, DIVISION HEAD, BOARD MEMBER OF A COUNTY AUTHORITY OR AN EXECUTIVE
DIRECTOR AS A:
SPOUSE YES NO
CHILD YES NO
PARENT YES NO
STEP CHILD YES NO
IN-LAW YES NO
SIBLING YES NO
NEPHEW YES NO
NEICE YES NO
FIRST COUSIN YES NO
IF YES, COUNTY OFFICIAL(S) NAME AND TITLE:
The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on
this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis
prohibited by local, state or federal law.
I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any
time, with or without cause and without prior notice. I understand that no representative of the employer has the authority
to make any assurances to the contrary.
Anyone unable to complete this application form due to a disability may request a reasonable accommodation to do so.
Such a request will not play any role in the decision to offer a position or hire any Applicant. Hiring decisions are based on
an applicant’s ability to perform the essential functions of the job.
I certify that all of the above information is true and complete. I understand that if I provide any false or
materially incomplete information on this application or for any job related physical or mental examination,
I may be terminated, if hired or be ineligible for hiring.
SIGNATURE: _____________________________________________ DATE: ______________________
TO BE COMPLETED BY OFFICE PERSONNEL AND/OR HIRING DEPARTMENT:
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