APPLICANT’S STATEMENT/RELEASE
I certify that the answers I have made to all of the questions in this application and accompanying documents are true
and complete to the best of my knowledge. I understand that if this application is not completed in its entirety, it will
not be processed and I will be automatically disqualified. I understand that I am responsible for the correctness of this
application. I also understand that a background check may be required prior to and after employment.
In accordance with the Drug and Alcohol Free Workplace policy, drug testing may be required. I understand that any
offer of employment which may be made to me by the Appointing Authority or Designee (Employer) is contingent upon
my successfully passing a Drug Screening Test. I hereby give my consent to the Employer to conduct a drug test that
will be performed by a laboratory selected by the Employer. I also understand and agree that if the pre-employment
Drug Screening Test indicates a violation of the Drug and Alcohol Free Workplace Policy, any contingent job offer
which may be or has been made to me will be null and void. I understand that the decision of the Employer shall be
final.
In addition to drug testing prior to employment, in accordance with the Drug and Alcohol Free Workplace policy, the
Employer reserves the right to perform, and I waive any right to object to, mandatory urinalysis to detect alcohol abuse,
illegal drug abuse, or substance abuse, if I become employed by Clark County.
I understand that any offer of employment is conditional upon proof of legal authorization to work in the United States
as required by the Immigration Reform and Control Act.
I further understand and acknowledge the Employer reserves the right to require me to submit to any requested medical
and/or psychological examination(s) after a job offer has been made and prior to my first day of employment. Where
required, such examination(s) will be performed by a licensed physician or medical practitioner of the Employer’s
choosing. If I fail any of the required pre-employment tests relating to drug, alcohol, or substance abuse, or am
otherwise found to be physically incapable of performing the job for which I am applying, the application procedure
will be terminated, and I will NOT be employed.
By signing this document I submit to the aforementioned tests and procedures, if required. I permit Clark County to
conduct a background investigation concerning matters related to my application for employment. As a result of this
background investigation I understand that Clark County will be seeking information from prior employers and other
individuals that I may not have disclosed. By signing this release, I hereby give my consent to all prior employers and
educational institutions to provide necessary information to Clark County. I hereby release, hold harmless, and agree
not to sue or file any claim of any kind against Clark County, any current or former employer, educational institution,
any officer or employee of either, that in good faith furnishes written or oral references as requested by Clark County to
complete its investigation. If I refuse to consent to any required screenings or background checks, Clark County shall
not accept or further process my application for employment. I further acknowledge that this document is a public
document and subject to the Ohio Public Records Act.
Signature of Applicant Date
This box is to be used only by Personnel during the evaluation process. Do NOT complete now.
Application Received ____________________________ Letter Mailed________________________
Social Security Number__________________________ Date of Birth_________________________
Driver’s License # ______________________________ State Issued__________________________
First Interview__________________________________ Second Interview
_____________________
Digitally signed by Nichi Baker
DN: cn=Nichi Baker, o=Clark County, ou=Personnel, email=nbaker@clarkcountyohio.gov, c=US
Date: 2015.06.30 12:02:32 -04'00'
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