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BLAINE COUNTY EMPLOYMENT APPLICATION AN EQUAL OPPORTUNITY EMPLOYER (BLAINE COUNTY)

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Employment Application
Page 1
BLAINE COUNTY
EMPLOYMENT APPLICATION
AN EQUAL OPPORTUNITY EMPLOYER
The information contained on this form is sought in good faith.
It will not be used in any way to discriminate against any applicant for
employment in violation of state and federal law.
IMPORTANT: Please type or print in ink. You may respond to sections 4 and 5 on separate sheets
of paper if all relevant blocks are completed and the same format is followed. On each sheet write
your name and job title for which you are applying. You may submit a legible photocopied
application. If you photocopy your application, leave sections 1, 2, and 3 blank and complete these
sections each time you apply. You must sign and date in ink each application you submit. LATE,
INCOMPLETE or UNSIGNED applications will not be considered.
PLEASE READ THE JOB VACANCY ANNOUNCEMENT CAREFULLY TO FIND: (a) what
attachments must be submitted (supplement questions, transcript, Employment Preference Form, etc.);
(b) where to submit your application; (C) the required special qualifications or licenses; and (d) the
closing date for receipt of applications. An application tailored to the position is to your advantage.
Under state and federal law, qualified applicants with disabilities are entitled to reasonable
accommodations. Modifications or adjustments may be provided to assist applicants to compete in
the recruitment and selection process, to perform the essential duties of the job or to enjoy equal
benefits and privileges of employment available to other employees. An applicant must request an
accommodation when needed.
Employment Preference: The Veterans’ Employment Preference Act and the Persons with
Disabilities Employment Preference Act provide preference in public employment for certain
military veterans and people with disabilities or their eligible relatives. An applicant claiming
employment preference must complete an Employment Preference Form, available through your local
Montana Job Service. The applicant must indicate at the bottom of page one of this application form
the necessary documentation is attached. Contact your local Montana Vocational Rehabilitation
Services Office (Department of Public Health and Human Services) for details on obtaining persons
with disabilities preference certification. For more information, contact your local Job Service.
Employment Application
Page 2
1. Name 2. What Position are you apply for?
Last First MI
Address: Department:
Position Title:
Phone: Job Location:
Work Home
3. My signature below certifies all information on this and all attached pages (checked below) are true,
correct and complete to the best of my knowledge and contain no willful falsifications or
misrepresentations. Falsifications or misrepresentations may disqualify me from consideration for
employment with Blaine County or, if hired, may be grounds for termination at a later date.
Employers may be contacted as references. In the spaces below, I have checked attachments,
including those required in the job vacancy announcement. I understand if I am the final applicant for
the applied position, a criminal background check may be conducted and the results thereof may
disqualify me from consideration for employment with the County.
to Supplement Questions -key Certification
Résumé
SIGNATURE: DATE SIGNED:
4. EDUCATION: You may respond to this section on a separate sheet of paper (on each sheet write
your name and job title for which you are applying) if all relevant blocks are completed and the same
format is followed.
High School Name and Address
Did you receive Diploma or Equivalency Certificate? Yes No
If you chose “No” above, please enter the highest grade that you completed _________
College, University,
Other Schools &
Training Courses
Name and Location
Dates
Attended
Degree/
Certificate
Received?
Degree/
Certificate
Date
Major/
Minor
Field
Credits Earned-
Indicate Quarter
or Semester Credits
Employment Application
Page 3
List current Professional Licenses, Registration, or Certifications (engineering, medical, CPA, etc.)
Type of License
Endorsement/Restriction
(If Applicable)
Date
Licensed
List other skills, education, experience and abilities below. You may also include a list of equipment
that you know how to use. (If you need more space, continue on an attached sheet of paper.)
5. EMPLOYMENT EXPERIENCE: List your work and/or volunteer experience with emphasis on
experience that is relevant to the position for which you are applying. Begin with your present or
most recent experience. Include military service that would help you qualify. You may continue this
section on a separate sheet of paper if all the same format is followed. Include your name and the job
title for which you are applying on each sheet. This information must be completed even if a resume
is submitted.
Notice to Applicants: Information you provide on this application is subject to verification. Your
current and past employers may be contacted as references.
Do you want to be informed before we contact your current and past employers? Yes No
Employment Application
Page 4
Name & Complete Address of Employer:
Your Job Title:
Type of Business: Dates Employed / to /
Immediate Supervisor(s): Phone No.
Avg. Hrs. Per Week Total Time Employed Yrs/Mo
Full-Time Part-Time Volunteer
Describe duties, including knowledge, skills, abilities required, employees supervised, and
accomplishments:
Reason for Leaving:
Name & Complete Address of Employer:
Your Job Title:
Type of Business: Dates Employed / to /
Immediate Supervisor(s): Phone No.
Avg. Hrs. Per Week Total Time Employed Yrs/Mo
- -Tim
Employment Application
Page 5
Describe duties, including knowledge, skills, abilities required, employees supervised, and
accomplishments:
Reason for Leaving:
Name & Complete Address of Employer:
Your Job Title:
Type of Business: Dates Employed / to /
Immediate Supervisor(s): Phone No.
Avg. Hrs. Per Week Total Time Employed Yrs/Mo
- -
Describe duties, including knowledge, skills, abilities required, employees supervised, and
accomplishments:
Reason for Leaving:
Name & Complete Address of Employer:
Your Job Title:
Employment Application
Page 6
Type of Business: Dates Employed / to /
Immediate Supervisor(s): Phone No.
Avg. Hrs. Per Week Total Time Employed Yrs/Mo
- -
Describe duties, including knowledge, skills, abilities required, employees supervised, and
accomplishments:
Reason for Leaving:
Employment Application
Page 7
MONTANA PREFERENCE ACTS
If you are claiming preference under Montana Veterans’ Public Employment Preference Law
(MCA 39-29-101 et. Seq., ARM 2-221-3601) or Montana Persons with Disabilities
Employment Preference Act (MCA 39-30-103 et. Seq.), complete the following:
Veteran’s Employment Preference provides the addition of 5 percentage points (veteran) or
10 percentage points (disabled veteran or handicapped) to the applicant’s score when a
numerically scored selection procedure is used. To claim Veteran’s Employment Preference
you must be a U.S. Citizen and (check one of the boxes below):
( ) A Veteran separated under honorable conditions
( ) A Disabled Veteran separated under honorable conditions
( ) The spouse of a disabled veteran if the veteran’s disability prevents him/her from
working
( ) The unremarried surviving spouse of a veteran or disabled veteran
( ) The mother of a veteran, IF THE VETERAN lost his/her life under honorable conditions
while serving in the Armed Forces, OR has a service-connected, permanent, and total
disability
You may claim Montana Persons with Disabilities Employment Preference as (check one of the
boxes below):
( ) A person with a disability person certified by DPHHS, or
( ) The spouse of a totally (100%) disabled person certified by DPHHS, and resides
continuously in Montana for at least one year immediately before applying for employment
NOTE: If you claim a preference, documentation must be attached. Please check which attachments
you have included:
DD-214 DPHHS Certification Other
Employment Application
Page 8
-READ CAREFULLY—
Do Not Write On This Page
Please make sure all required information is included (see job vacancy announcement).
1. Did you sign and date your application?
2. Have you read the job announcement to see what attachments must be submitted?
3. Have you checked boxes in Section 3 to indicate what attachments you have included?
4. Did you indicate the specific Position Title in Section 2?
5. Did you include a complete address for each employer listed in Section 5?
6. If you are claiming Veterans Employment Preference or Persons with Disabilities
Employment Preference, have you completed and attached the Employment Preference
Form and Documentation?
7. Did you attach all the application materials required by the vacancy announcement?
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BLAINE COUNTY EMPLOYMENT APPLICATION AN EQUAL OPPORTUNITY EMPLOYER (BLAINE COUNTY)

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Completed 19 January 2021

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