Date of Hire: Mo/Day/Yr.
Address: No. & Street City State Zip Code
Reason for Seeking New Employment
Date of Hire: Mo/Day/Yr.
Address: No. & Street City State Zip Code
Reason for Seeking New Employment
OTHER INFORMATION
Other (Explain)
And Skills
Describe Any Equipment Extensively Operated By You (Office, Construction, Buses, Trucks, Etc.)
Current License: Driver Commercial Driver License
Chauffer
None
No.: State:
License Ever Suspended or Revoked? Yes No
Date: Reason:
Ever Convicted of A Crime (except minor traffic violations)? Yes No
Dates: Offenses:
Ever Collected Money or Bonded? Yes No
For Whom:
List Any Specialized Training, Certificates or Achievements:
How did you hear about this employment opportunity?
Do you have any relatives or friends currently employed by the County? Yes (List names) No
Have you reviewed the job description or posting for the position sought?
REFERENCES
List Three (Local Area Residents), If
Available
Winnebago County, Iowa Does Not Discriminate On the Basis of Race, Color, National Origin, Sex, Sexual Orientation, Gender
Identity, Religion, Age, or Disability in Employment or the Provision of Services.
I hereby certify that the answers given and statements made by me on this Employment Application are true & correct & that there are no material
omissions. I authorize my present and former employers to give County officials any information regarding me or my performance and release such
employers, including their representatives & their companies, from all liability from damage for providing requested information. I understand that
should investigation disclose misrepresentation or falsification, I will be dismissed immediately, my application will be rejected and I will be
disqualified from making future application with the County.
I understand that any employment offered by the County is “employment at will” & I may be terminated for any reason not violative of law (or a
collective bargaining agreement where applicable). I understand my driving and any criminal records may be checked and I agree to submit to a pre‐
employment physical examination at County expense following a conditional offer of employment. I also understand that Winnebago County
,
Iowa
has a strict policy against illegal drug involvement by employees that can result in immediate disqualification or dismissal from employment for any
such illicit activities occurring on or off the job. You may be subject to random drug testing. I also understand the County strictly enforces the Iowa
Smokefree Air Act and employees violating said Act are subject to discipline, up to and including discharge.
Read the Above Statement Carefully!
