Fill - Free fillable Human Resources Beaver County Courthouse 810 Third St. (Beaver County Information Technology) PDF form

Human Resources

Beaver County Courthouse

810 Third St.

Email: HR@beavercountypa.gov Beaver, PA 15009 Phone: 724-770-4413

APPLICATION FOR EMPLOYMENT

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age,

disability, marital or veteran status, sexual orientation, or any other legally protected status. Applicants requiring

accommodation in the application or hiring process should contact the Office of Human Resources for such assistance.

Position(s) Applied For:_________________________________________Date of Application:____________________

Referral Source: County Website Job Search Site Other_______________________________________

Last Name (print above) First Name Middle Name

Current Address -Number and Street (print above) City, State, Zip

Length of time at current address above Prior address (if less than one year at current address)

Best Contact Number (Cell or Home Phone) Social Security Number

If less than 18 years of age, can you furnish a work permit? Yes No

Have you ever been employed by Beaver County ? Yes No

If yes, when?

Email Address

Are you a U.S. Veteran? Are you currently employed? Yes No

May we contact you at work? Yes No

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?

Yes No (Proof of citizenship or immigration status will be required upon employment)

Are you available to work (check all that apply)

Full Time _______ Part Time _______

Shift Work ______ Temporary ______

Are you currently on “lay off” status and subject to recall?

Yes

On what date will you be available for work?

Driver’s License number (if required by job)

EDUCATION

School

Name and Address of School

Course of Study

Years

Completed

Degree or Diploma

High School

Undergraduate

College

Graduate

Professional

Other

(Specify)

Skills and Qualifications: Summarize special skills and qualifications acquired from employment or other experiences

that may qualify you to work for Beaver County:

__________________________________________________________________________________________________

No

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job related military service assignments and volunteer activities. You

may exclude organizations which indicate race, color, religion, gender, national origin, age, disability or other protected

status. List your last three (3) employers, assignments or volunteer activities, starting with the most recent, including

military experience. Explain any gaps in employment in comments section below:

Employer/Volunteer Telephone

Dates Employed

Summarize the nature of the work

performed and job responsibilities:

From

To

Address

Job Title

Hourly Rate/Salary

Starting

Immediate Supervisor and Title

$

Per

Reason for Leaving

Hourly Rate/Salary

Final

May we contact Yes No Later

$

Per

Employer/Volunteer Telephone

Dates Employed

Summarize the nature of the work

performed and job responsibilities:

From

To

Address

Job Title

Hourly Rate/Salary

Starting

Immediate Supervisor and Title

$

Per

Reason for Leaving

Hourly Rate/Salary

Final

May we contact Yes No Later

$

Per

Employer/Volunteer Telephone

Dates Employed

Summarize the nature of the work

performed and job responsibilities:

From

To

Address

Job Title

Hourly Rate/Salary

Starting

Immediate Supervisor and Title

$

Per

Reason for Leaving

Hourly Rate/Salary

Final

May we contact Yes No Later

$

Per

Comments:_________________________________________________________________________________________

__________________________________________________________________________________________________

REFERENCES

List name and telephone number of three business/work references who are not related to you and who are not

previous supervisors. If not applicable, list three school or personal references that are not related to you.

1. Name __________________________________ Phone No.___________________________

Address_______________________________________________________________________________

2. Name __________________________________ Phone No.___________________________

Address_______________________________________________________________________________

3. Name __________________________________ Phone No.___________________________

Address_______________________________________________________________________________

**************************************************************************************************

APPLICANT’S STATEMENT

I certify the answers given herein are true and complete to the best of my knowledge.

I authorize the County the right to investigate all references and to secure additional information about me if job

related. I hereby release from liability the County, and its’ representatives for seeking such information and all other

persons, corporations or organizations for furnishing such information.

This application for employment shall be considered active for a period of one (1) year. Any applicant wishing to be

considered for employment, beyond this time period, should submit a new application to the Human Resources Office.

Beaver County is an Equal Opportunity Employer (EOE). The County does not discriminate in employment, and no

question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment

on a basis prohibited by local, state, or federal law.

I certify that the information contained in this application is true and correct and complete. I understand that false

information or omission may result in the rejection of this application or termination from employment. I further

understand that any offer of employment is subject to satisfactory completion of a medical examination including a

drug test.

Signature of Applicant____________________________________________Date_________/_________/__________

Employment Applicant’s Nepotism Averment

(Revised July 30, 2014)

The County of Beaver has a Nepotism Policy that prohibits a job applicant from working for the County, if that applicant

is the parent, child, spouse, or sibling of a current member of the Board of Commissioners or their current secretaries or a

Beaver County Department Head.

By signing this form, you swear that you have read it and are not so related and that if it is later determined that you

have not been truthful and are, in fact, so related, you will immediately be terminated from employment with Beaver

County.

Exclusions to this policy as passed under resolution 032896-20 are as follows: Court of Common Pleas of Beaver County

(includes Domestic Relations, Adult Probation, Juvenile Probation, and District Justices offices). Also excluded are those

offices under the Civil Service system (CYS, MH/MR, and Aging). Row officers are excluded (Controller, Recorder of

Deeds, Treasurer, Register of Wills, Clerk of Courts, District Attorney, Sheriff’s Office, Prothonotary, Jury Commissioner,

Coroner)

Those who marry during the course of employment are also excluded from this Policy.

Signature:

Date:

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