This application will remain active for 90 days.
Reapplication is necessary after that time period.
Employment Application
Please complete all questions for employment consideration
Name
Present Address
Street City State Zip
Home Phone How did you hear of us?
If employee referral, please provide their name
Type of work or position applied for? Full Time Part Time
Date Available to
Days Available Hours Available Begin work
Describe why you are qualified for the position
(Attach resume if possible)
Compensation requirements Are you over 16? Yes No
Have you been employed by us before? Yes No If yes, when?
Have you applied for Date and
employment with us previously? Yes No Result
If you have relatives employed with us, their name/relationship
If you would be engaged in any other work while in our employ, please explain
If hired, can you demonstrate eligibility to work in the United States? Yes No
Has a former employer ever disciplined you for tardiness or absenteeism? Yes No
If yes, please explain:
Would a former employer categorize your attendance as meeting expectations? Yes No
If no, please explain:
Could you provide us a copy of your last performance evaluation? Yes No
After learning of the job duties, to the best of your knowledge would you be able to perform all the essential functions
of the position you are applying for? Yes No
If “no” please explain: ___________________________________________________________________________
______________________________________________________________________________________________
HISTORY OF EMPLOYMENT
List your complete employment record (including temporary, regular, and part-time) in date order.
List the most recent first. Include military service if applicable.
MOST RECENT EMPLOYER
Are you currently working for this company? Yes No If yes, may we contact? Yes No
Company Name Phone Number
Address
Supervisor’s Name/Title Contact Information:
Starting Position Ending Position
From To Beginning Salary Ending Salary
Brief Job Description
Reason for Leaving
EMPLOYER
Are you currently working for this company? Yes No If yes, may we contact? Yes No
Company Name Phone Number
Address
Supervisor’s Name/Title Contact Information:
Starting Position Ending Position
From To Beginning Salary Ending Salary
Brief Job Description
Reason for Leaving
EMPLOYER
Are you currently working for this company? Yes No If yes, may we contact? Yes No
Company Name Phone Number
Address
Supervisor’s Name/Title Contact Information:
Starting Position Ending Position
From To Beginning Salary Ending Salary
Brief Job Description
Reason for Leaving
If you were employed under a different name in any of these positions, give name and applicable company:
Account for any gaps in employment in the last 5 years (periods of 4 weeks or more)
From
To
Reason
EDUCATIONAL BACKGROUND
School Name/
Address
Dates
Attended
Date
Graduated
Grade Point / Honors
HIGH SCHOOL
N / A
N / A
BUSINESS / TRADE
COLLEGE / UNIV.
INDICATE TRAINING OR EXPERIENCE PERTINENT TO THE JOB
Computer Skills:
Equipment:
Vehicles:
Other Skills / Qualifications:
ACKNOWLEDGEMENT OF UNDERSTANDING AND CONSENT
Please read thoroughly before signing
It is understood that this application is not an obligation of employment.
I hereby authorize the County to investigate all references and former employment, and I release from
liability those supplying such information. I understand that upon offer of employment, I may be required to
take a drug test at the County’s expense. I realize that the offer of employment is contingent upon my test
results being substance-free and satisfactory information being received from reference sources.
I will provide proof of my eligibility to work on the date of hire as required by “The Immigration Reform
and Control Act of 1986”.
I understand that the County can make no guarantee as to the numbers of hours that I may be assigned from
week to week, and any reduction in hours can affect my compensation and benefits. I also understand that I
may be required to change days off and scheduled hours on a temporary or regular basis in order to continue
my employment. Also, I understand that the County reserves the right to transfer me to another position, as
business necessitates, and my continued employment may be predicated upon my acceptance of said transfer.
I understand that evenings or weekends may be part of any schedule I may be assigned.
I understand that my employment is not governed by any written or oral contract and is considered an “at
will” arrangement. I understand that I am free, as is the County, to terminate employment at any time for
any reason, so long as there is no violation of applicable Federal or State law unless modified by a collective
bargaining agreement.
I state that the information on this application is true and complete. False statements, misrepresentations, or
omission may be cause for cancellation of an employment offer or termination, even if already employed. I
agree that I have read and understand the above acknowledgements and agreements and recognize all of the
above as conditions of employment.
I understand that if employed in a position governed by a collective bargaining agreement to which the
County is a party that once I am covered by that agreement its terms may supersede some of the statements
in this acknowledgement of understanding.
Signature Date
DO NOT WRITE BELOW THIS LINE FOR EMPLOYER USE
Management Approval
Start Date Exempt/Rate Non-Exempt/Rate
Full-Time Part-Time Position
AN EQUAL OPPORTUNITY EMPLOYER
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