Employment Application
Date:
Name:
Address:
State/Province:
Zip/Postal Code:
Home Phone:
Cell Phone:
Positions applied for:
When available to begin work?
BOARD OF MORROW
COUNTY COMMISSIONERS
80 North Walnut Street
MOUNT GILEAD, OHIO 43338
Phone: 419-947-4085
Fax: 419-947-1860
www.morrowcountyohio.gov
An Equal Opportunity Employer
Department in which you are applying:
Education
Type of School Name of School and Address Did you graduate? Major or Degree
High School
College Bus. or
Trade School
Graduate School
Other
Do you have any commitments (e.g., second job, school, etc.) which might interfere with
or adversely affect your employment should we select you for a position?
yes no
If yes, please explain
Do you possess a valid drivers license?
yes no
If no, can you obtain one prior to employment?
yes no
Are you eligible to work in the United States?
yes no
Continue on the next page
Are you a resident of Ohio?
noyes
If no, are you willing to become a resident
upon employment?
yes no
Print Form
Previous Employment (list up to 3)
1.
Name of Employer:
Name of last supervisor:
Dates of employment:
From: To:
Salary:
From: To:
Complete Address:
Phone #:
Last job title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
May we contact your employer: yes no
2.
Name of Employer:
Name of last supervisor:
Dates of employment:
From: To:
Salary:
From: To:
Complete Address:
Phone #:
Last job title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
May we contact your employer: yes no
Continue on the next page
3.
Name of Employer:
Name of last supervisor:
Dates of employment:
From: To:
Salary:
From: To:
Complete Address:
Phone #:
Last job title:
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
May we contact your employer: yes no
Skills:
Typing:
Computer:
PC Mac Both
Applications (list all that apply):
Other Skills:
Please list 3 references other than relatives and previous employers
Name
Position
Company
Telephone
Use this space to add any additional information necessary to describe your full qualifications for the position which you are applying:
Relationship
Continue on the next page
PLEASE READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. INDICATE YOUR UNDERSTANDING OF AND CONSENT TO,
THE CONTENTS AND CONDITIONS OF EACH PARAGRAPH BY PLACING YOUR INITIALS AT THE END OF EACH PARAGRAPH. IF
YOU HAVE ANY QUESTIONS REGARDING THESE PARAGRAPHS, CONTACT THE EMPLOYER BEFORE INITIALING THE PARAGRAPH.
1. I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any
medical examination that the employer deems necessary to determine whether I can physically perform the essential functions
of the position, with or without reasonable accommodation when necessary. I understand and accept that this may include
drug, alcohol or substance abuse testing.
Initials:
2. If employed, I understand and accept that, depending on the department in which I am applying for employment, I may be
required to work evening or night shifts including weekends, be on call and/or work mandatory overtime hours.
Initials:
3. I understand and accept that if any information required in this application is found to be falsified or intentionally excluded,
my application may be disqualified from further consideration. I further understand and accept that if I am employed by the
employer, I may be subject to disciplinary action, including termination, if any information required by this application has been
falsified or intentionally excluded.
Initials:
4. I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees. I also
understand and accept that the various law enforcement and informational agencies that exchange information and data with
the employer require that the employer's employees do not have a past record of unlawful activities. Therefore, I understand
and accept that depending on the department in which I am applying for employment, it may be necessary for the employer
to investigate my background for any criminal or unlawful activity.
Initials:
5. I herby authorize the employers, schools and personal references named in the application to provide information regarding
me to the employer. I further authorize the release of personnel, academic and other records to the employer.
Initials:
I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THIS EMPLOYMENT APPLICATION IS TRUE, ACCURATE
AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS
APPLICATION. I UNDERSTAND THAT ANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATION PROVIDED MAY LEAD
TO WITHDRAWAL OF AN EMPLOYMENT OFFER OR TERMINATION FOLLOWING EMPLOYMENT. I RECOGNIZE THAT MY FUTURE
EMPLOYMENT WITH THE EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE OR
ALCOHOL ABUSE.
READ CAREFULLY BEFORE SIGNING:
I agree that any claim or lawsuit relating to my service with Morrow County must be filed no more than six (6) months after the
date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.
Applicant's Signature
Date