Fillable EMPLOYMENT APPLICATION Updated: 07-2015 Office of Personnel Management (Utah County Government)

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EMPLOYMENT APPLICATION Updated: 07-2015 Office of Personnel Management (Utah County Government)

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EMPLOYMENT APPLICATION Updated: 07-2015
Office of Personnel Management 100 East Center Street, Suite 3800, Provo, UT, 84606
Phone (801) 851-8158 ~ Email: ucpersonnel@utahcounty.gov ~Fax (801) 851-8166 ~ www.utahcountyonline.org
PLEASE READ INSTRUCTIONS ON PAGE 4 BEFORE COMPLETING APPLICATION
I. APPLICANT INFORMATION
Position Title ____________________________________________________________ Posting # _____________________
Name _______________________________________________________________ Soc. Sec. No. XXX - XX - __________
Other names previously used ____________________________________________________________________________
Address _____________________________________________________________________________________________
Street City State Zip Code
Phone: home ____________________ other ____________________ email _____________________________________
1. How did you become aware of the position for which you are applying? _______________________________________
2. If employed, are you willing to accept the approved salary for the position? ~ yes ~ no
II. VETERAN’S PREFERENCE: Please see additional instructions on page 4. This information is voluntary. However,
DISCLOSURE OF THE INFORMATION IS REQUIRED IF YOU WISH TO BE GIVEN PREFERENCE.
Do you claim Veteran's Preference? If Yes: ~ As a veteran
~ NO ~ YES (Please attach documentation) ~ As a spouse, or as an unmarried widow or widower of a veteran
III. TRAINING AND EDUCATION: You must complete all applicable items in this section. The information you give regarding
your training and education will be used to determine if you meet minimum qualifications.
HAVE YOU GRADUATED FROM HIGH SCHOOL OR RECEIVED A HIGH SCHOOL EQUIVALENCY DIPLOMA (GED)
9 YES 9 *NO *If no, indicate highest year completed: 9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 9 9 9 10 9 11 9 12
Name and Location of College or University
Dates Credits Completed
Major/Minor
Did you
Graduate?
Yes No
Type of
Degree
Date of
Degree
From To
Semester
Hours
Quarter
Hours
PROFESSIONAL LICENSE OR CERTIFICATE, IF REQUIRED
Type Serial Number Date Issued Expiration Date
LANGUAGES: List languages you speak, read and write other than English _____________________________________
IV. EXPERIENCE: You must complete all applicable items in this section. The information you give regarding your experience will
be used to determine if you meet minimum qualifications. Begin with your present or most recent job and describe, in the boxes
below, all periods of employment such as paid (full or part time), volunteer (full or part time), self employment, and/or military service.
Account for your time during any intervals of unemployment other than when attending school. Attach addendum if necessary, using
the same format. Unless requested on job posting, RESUMES WILL NOT BE ACCEPTED.
EMPLOYER'S NAME AND PHONE NUMBER:
COMPLETE ADDRESS:
YOUR TITLE: FROM ________________________ TO ____________________________
MO. YR. MO. YR.
~ FULL TIME ~ PART TIME ~ VOLUNTEER ~ OTHER HOURS PER W EEK _________ LAST PAY $___________PER___________
SUPERVISOR’S NAME, TITLE, AND PHONE NUMBER:
DUTIES:
REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT:
EMPLOYER'S NAME AND PHONE NUMBER:
COMPLETE ADDRESS:
YOUR TITLE: FROM ________________________ TO____________________________
MO. YR. MO. YR.
~ FULL TIME ~ PART TIME ~ VOLUNTEER ~ OTHER HOURS PER W EEK _______ LAST PAY $____________PER____________
SUPERVISOR’S NAME, TITLE, AND PHONE NUMBER:
DUTIES:
REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT:
EMPLOYER'S NAME AND PHONE NUMBER:
COMPLETE ADDRESS:
YOUR TITLE: FROM _______________________ TO ____________________________
MO. YR. MO. YR.
~ FULL TIME ~ PART TIME ~ VOLUNTEER ~ OTHER HOURS PER W EEK _______ LAST PAY $___________PER_____________
SUPERVISOR’S NAME, TITLE, AND PHONE NUMBER:
DUTIES:
REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT:
V. REFERENCES: List three persons who are not related to you and who have definite knowledge of your qualifications for the position for which you are
applying.
FULL NAME PRESENT BUSINESS OR HOME ADDRESS
(STREET, CITY, STATE, ZIP)
BUSINESS OR
OCCUPATION
PHONE NUMBER
~ YES ~ NO 1. Have you, since the age of 18, been convicted of a crime, excluding minor traffic offenses? If yes, give dates, details and penalties for each
occurrence, including dates of any probationary periods on a separate sheet. (Note: Each conviction will be judged in relation to time, seriousness,
circumstances, and relationship to the position sought, and will not necessarily bar you from employment.)
~ YES ~ NO 2. Have you ever been discharged or forced to resign? If yes, please explain on a separate sheet.
~ YES ~ NO 3. W ould accommodation/assistance be helpful to you in taking the examination for this position? If yes, describe on a separate sheet.
~ YES ~ NO 4. If the position for which you are applying requires driving a vehicle (see posted job announcement), do you possess a current driver's license?
If yes, specify state issued:_________________________________type: ____________________________________
~ YES ~ NO 5. If the position for which you are applying is hazardous in nature, including but not limited to working with or around heavy equipment or hazardous
material (see posted job announcement), are you 18 years of age or older?
~ YES ~ NO 6. Have you ever been employed by Utah County Government? If yes, please include applicable information in the Experience section of this
application.
~ YES ~ NO 7. Are you eligible to work in the U.S.?
~ YES ~ NO 8. Are you willing to have your current employer contacted regarding your employment record?
~ YES ~ NO 9. Are you related to someone currently employed by Utah County?
If yes, Name_____________________________ Dept.____________________ Relationship__________________________________
VI. READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS STATEMENT: I affirm that this application contains
no misrepresentation or falsification and that the information is true and complete to the best of my knowledge and belief. I am aware that
should investigation at any time disclose any such misrepresentation or falsification, my application will be rejected or, if employed by Utah
County Government, I may be terminated from employment. I further authorize any of my employers (subject to my answer to the
previous question regarding current employer) or references to give Utah County Government any private or confidential
information concerning my employment record. Finally, I authorize that copies of this application and attachments may be provided
to hiring County departments.
______________________________________________________________________________________ _________________________________________
SIGNATURE OF APPLICANT DATE
VII. COMPLETE THIS SECTION ONLY FOR LAW ENFORCEMENT RELATED POSITIONS
~ YES ~ NO Are you currently POST (Peace Officer Standards and Training) certified in Utah or another state? If yes, circle all that apply:
Special Functions Specify State: _____________________________
Corrections Specify State: _____________________________
Law Enforcement Officer Specify State: _____________________________
Dispatcher Specify State: _____________________________
~ YES ~ NO Are you 21 years of age or older? (Law Enforcement/Corrections only)
READ THE FOLLOW ING CAREFULLY BEFORE SIGNING THIS STATEMENT: Having made application for employment with Utah County Government for
the position of _____________________________________________________, I hereby authorize Utah County Government to conduct a detailed
background investigation and understand that all information pertaining to such application and investigation will be kept confidential and released only to
authorized individuals. I understand that should any investigation disclose any misrepresentation, falsification, omission or concealment of material fact, my
application may be rejected and my name removed from the eligibility list, and if already employed, I may be dismissed. I also understand that certain
information or offenses may preclude me from further consideration or result in termination. I hereby release your organization or any other agency involved in
releasing this information from any civil or criminal liability arising under the Federal Rights and Privacy Act or other applicable State and County statutes.
_____________________________________________________________________________________ _______________________________________
SIGNATURE OF APPLICANT DATE
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UTAH COUNTY GOVERNMENT EMPLOYMENT APPLICATION
INSTRUCTIONS TO APPLICANTS
1 . Complete an official Utah County employment application for every position for which
you are applying. If more space is needed, attach an addendum using the same application
format. Unless requested on the job posting, RESUMES WILL NOT BE ACCEPTED. Sign
your application and return it with all required attachments to the Personnel Office by 5:00
p.m. (MST) on or before the closing date. NO POSTMARKS.
2 . Submit copies of official college or university transcripts with your application if you
wish to receive credit for your education.
3 . Veteran’s Preference. Refer to Title 71 UCA 10 as amended for eligibility requirements
for veteran’s preference. Persons claiming veteran's preference must submit a photocopy of
the veteran’s honorable discharge (such as a DD-214) showing the dates of service with each
application form. A spouse or unmarried widow or widower of a veteran must also submit a
copy of their marriage license as well as the DD-214.
OTHER INFORMATION REGARDING APPLYING FOR A UTAH COUNTY GOVERNMENT POSITION
1. Applicants may be required to undergo drug testing as a condition of employment.
2. False statements, evidence of fraud or deceit in connection with this application will disqualify you from examination or
employment, and if discovered after employment are grounds for discharge. This application and all attached documents
are official records of Utah County Government and cannot be returned.
3. Your completed application will be used to determine your eligibility for the position for which you are applying.
4. Competitive Career Service positions may require an examination by Utah County Government. Examination can consist
of one or a combination of the following: written examination, oral examination, performance examination. If you are
applying for a position that requires an examination, you will be notified of the time and place of your examination.
5. Federal law requires supervisors/employers to review documents verifying your identity and eligibility to work in the United
States and to complete Form I-9 (Employment Eligibility Verification). You will be required to provide this documentation.
Supervisors/employers are in violation of the law if the documents are not reviewed and Form I-9 is not completed.
6. If employed, the Personnel Office will require a copy of your current Social Security Card to ensure County employment
forms match the name on the Social Security Card.
7. Your application will not be rejected because of your race, color, national origin, religion, sex, age, or disability, except as
legally required.
8. If you are invited to a hiring interview, it is your responsibility to provide the selection official with additional documents as
requested.
9. If you desire further information regarding Utah County employment, please refer to www.utahcountyonline.org or contact
the Utah County Personnel Office.
UTAH COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER
It is the policy of Utah County Government to provide and promote equal opportunity employment, compensation and other terms and conditions of
employment without discrimination because of race, color, sex, religion, national origin, age or disability. The County provides reasonable
accommodations to the known disabilities of applicants in compliance with the Americans with Disabilities Act.
ADDENDUM FOR ADDITIONAL WORK EXPERIENCE TO THE UTAH COUNTY EMPLOYMENT APPLICATION: List jobs and describe, in the boxes
below, all periods of employment such as paid (full or part time), volunteer (full or part time), self employment, and/or military service. Account for your time
during any intervals of unemployment other than when attending school. Unless requested on the job posting, RESUMES WILL NOT BE ACCEPTED.
EMPLOYER'S NAME AND PHONE NUMBER:
COMPLETE ADDRESS:
YOUR TITLE: FROM ____________________TO ____________________________
MO. YR. MO. YR.
~ FULL TIME ~ PART TIME ~ VOLUNTEER ~ OTHER HOURS PER WEEK ______ LAST PAY $___________PER________
SUPERVISOR’S NAME, TITLE, AND PHONE NUMBER:
DUTIES:
REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT:
EMPLOYER'S NAME AND PHONE NUMBER:
COMPLETE ADDRESS:
YOUR TITLE: FROM ____________________ TO____________________________
MO. YR. MO. YR.
~ FULL TIME ~ PART TIME ~ VOLUNTEER ~ OTHER HOURS PER WEEK ____ LAST PAY $______________PER_______
SUPERVISOR’S NAME, TITLE, AND PHONE NUMBER:
DUTIES:
REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT:
EMPLOYER'S NAME AND PHONE NUMBER:
COMPLETE ADDRESS:
YOUR TITLE: FROM _______________________ TO ________________________
MO. YR. MO. YR.
~ FULL TIME ~ PART TIME ~ VOLUNTEER ~ OTHER HOURS PER WEEK ____ LAST PAY $_____________PER________
SUPERVISOR’S NAME, TITLE, AND PHONE NUMBER:
DUTIES:
REASON FOR LEAVING OR SEEKING OTHER EMPLOYMENT:
APPLICANT DATA RECORD
Utah County Government is an equal opportunity employer and complies with applicable government regulations. It is illegal for any agency
or organization to discriminate in hiring based on race, color, sex, religion, national origin, age or disability.
THE INFORMATION REQUESTED ON THIS SHEET IS VOLUNTARY. This information will assist Utah
County Government in applicant tracking, reporting, and other legal requirements. Failure to answer will not
subject applicants to disparate treatment.
We would appreciate your cooperation in filling out this information to help us comply with government
regulations. This data will be maintained in a separate, private research file.
Position applied for ______________________________Posting Number: ______________________________
Date _________________________ Veteran:
GYes
GNo
Referral Source ___________________________________________________________________
EQUAL EMPLOYMENT INFORMATION
(Please check applicable information)
Sex: ~ Female
~Male
Age: ~Under 40
~ 40 or Over
Please mark one or more of the following five (5) racial categories which apply to you.
~WHITE: A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF EUROPE, THE MIDDLE EAST, OR NORTH AFRICA
~BLACK OR AFRICAN AMERICAN: A PERSON HAVING ORIGINS IN ANY OF THE BLACK RACIAL GROUPS OF AFRICA
~ASIAN: A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF THE FAR EAST, SOUTHEAST ASIA, OR THE INDIAN
SUBCONTINENT INCLUDING, FOR EXAMPLE, CAMBODIA, CHINA, INDIA, JAPAN, KOREA, MALAYSIA, PAKISTAN, THE PHILIPPINE ISLANDS,
THAILAND, AND VIETNAM.
~AMERICAN INDIAN OR ALASKA NATIVE: A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF NORTH AND SOUTH AMERICA
(INCLUDING CENTRAL AMERICA), AND WHO MAINTAINS TRIBAL AFFILIATION OR COMMUNITY ATTACHMENT.
~NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF HAWAII, GUAM,
SAMOA, OR OTHER PACIFIC ISLANDS.
Please mark the following ethnicity category that applies to you:
~HISPANIC OR LATINO: A PERSON OF MEXICAN, PUERTO RICAN, CUBAN, CENTRAL OR SOUTH AMERICAN, OR OTHER SPANISH CULTURE
OR ORIGIN, REGARDLESS OF RACE.
~NOT HISPANIC OR LATINO
* TO BE SEPARATED BY PERSONNEL OFFICE ONLY *
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EMPLOYMENT APPLICATION Updated: 07-2015 Office of Personnel Management (Utah County Government)

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Completed 6 August 2020

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