MEDINA COUNTY
EMPLOYMENT APPLICATION
Please submit one application per position to the address indicated on the job posting . Applications lacking sufcient infor-
mation will be rejected. It is your responsibility to assure that your application is received by the closing date. Please be
sure to ll out all sides of this form. Also please note that this completed form will become a public record when submitted to
a government agency.
Fill in the information in the area below:
Job Title _______________________________________________________ FT/PT __________________________
Department ____________________________________________________ Deadline Date ___________________
SUMMARY OF QUALIFICATIONS
In the area below, describe briey the experience, education, training, and other factors that qualify you for the position for
which you are applying. Refer to the Minimum Qualications and any position-specic qualications posted for this position.
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PERSONAL INFORMATION
Last Name _______________________________________ First Name ______________________________ Middle Initial _____
Home Address ________________________________________________________________________________________________
City ____________________________________________ State ________ Zip _______________ County ____________________
Phone: ( ________ ) ____________________________ c Cell Email _______________________________________________
Social Security Number c c c - c c - c c c c
The following information will be used only if it is directly related to the position for which you are applying:
YES NO
1. Are you willing and able to secure an Ohio Driver’s License, if a license is required? c c
2. If the position requires travel, can you supply your own transportation? . . . . . . . . . . c c
3. Have you ever been employed in the state or county service of Ohio? . . . . . . . . . . c c
If you are currently a State employee: Job Title ________________________________ Barg. Unit _______________
If you answered “YES” to question #3, please explain fully.
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LICENSES, REGISTRATION, AND CERTIFICATES
Be sure to include any valid driver license or commercial driver license if required for the job title.
License/Certication Issued By Field/Trade/Specialization License/Certicate Number Expires
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EDUCATION
High School Graduate? c No c Yes
Name and Location of High School (City & State) _____________________________________________________________________
GED Certicate Number _________________________________ GED Issued By ______________________________________
Are you currently attending school (for College Intern and Student Help positions)? c No c Yes Level: ________________________
POST-HIGH SCHOOL EDUCATION
INCLUDING TECHNICAL SCHOOL, BUSINESS SCHOOL, PROFESSIONAL SCHOOL, COLLEGE AND UNIVERSITIES
SCHOOL NAME AND LOCATION MAJOR AREA(S) OF STUDY TYPE OF DEGREE OR CERTIFICATE
Please list below the specic course work areas at the high school level or beyond relevant to the position or examination for which you are
applying. Also indicate the number of courses you have successfully completed in each area. NOTE: A transcript may not be substituted
for this section, although you may be required to submit a transcript.
COURSE WORK AREA NO. OF COURSES COURSE WORK AREA NO. OF COURSES
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TRAINING AND OTHER QUALIFICATIONS
(Do not Include coursework already described above)
SUBJECT OR TITLE OF TRAINING ORGANIZATION LENGTH OF TRAINING
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List special equipment or machines you can operate: __________________________________________________________________
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List computer software in which you have skill, including word processing, spreadsheet, and database programs. Please indicate the name
of the specic software: _________________________________________________________________________________________
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List special clerical skills, including typing and shorthand: ___________________________________________ Typing Speed _______
List any additional relevant skills you have: __________________________________________________________________________
IF YOU NEED ADDITIONAL SPACE, ATTACH EXTRA COPIES OF THIS PAGE.
Employer __________________________________________ Phone ( _____ ) ________________ From _____ / ______ / ______
Month Day Year
Address _________________________________________________________________________
To _____ /______ / ______
City _______________________________________ State ____________ Zip ________________ Month Day Year
Reason for Leaving ________________________________________________________________ Salary __________________
Job Title _________________________________________________________________________ Supervisor’s Name and Title
Job Duties _______________________________________________________________________ ________________________
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Employer __________________________________________ Phone ( _____ ) ________________ From _____ / ______ / ______
Month Day Year
Address _________________________________________________________________________
To _____ /______ / ______
City _______________________________________ State ____________ Zip ________________ Month Day Year
Reason for Leaving ________________________________________________________________ Salary __________________
Job Title _________________________________________________________________________ Supervisor’s Name and Title
Job Duties _______________________________________________________________________ ________________________
________________________________________________________________________________ _______________________
Employer __________________________________________ Phone ( _____ ) ________________ From _____ / ______ / ______
Month Day Year
Address _________________________________________________________________________
To _____ /______ / ______
City _______________________________________ State ____________ Zip ________________ Month Day Year
Reason for Leaving ________________________________________________________________ Salary __________________
Job Title _________________________________________________________________________ Supervisor’s Name and Title
Job Duties _______________________________________________________________________ ________________________
________________________________________________________________________________ _______________________
Employer __________________________________________ Phone ( _____ ) ________________ From ______/______/______
Month Day Year
Address _________________________________________________________________________
To ______/______/______
City _______________________________________ State ____________ Zip ________________ Month Day Year
Reason for Leaving ________________________________________________________________ Salary __________________
Job Title _________________________________________________________________________ Supervisor’s Name and Title
Job Duties _______________________________________________________________________ ________________________
________________________________________________________________________________ _______________________
Employer __________________________________________ Phone ( _____ ) ________________ From _____ / ______ / ______
Month Day Year
Address _________________________________________________________________________
To _____ /______ / ______
City _______________________________________ State ____________ Zip ________________ Month Day Year
Reason for Leaving ________________________________________________________________ Salary __________________
Job Title _________________________________________________________________________ Supervisor’s Name and Title
Job Duties _______________________________________________________________________ ________________________
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EXPERIENCE
In the areas below, please list your past experience beginning with your most recent employment. Military experience
and volunteer work may also be included as employment. NOTE: In order to be considered for employment, you must ll in
the information below, accurately and completely. You may submit a resume in addition to completing this section.
SOCIAL SECURITY NUMBER NOTICE
Social Security Numbers (SSNs) are used to match individuals with their application/examination le. Disclosure of your SSN is voluntary;
however, a nine-digit number is necessary to process your application. Upon appointment and pursuant to Section 5101.312 of the Revised
Code and certain other laws and regulations, a request for a SSN is mandatory. Your SSN may be used for purposes including but not lim-
ited to the following: Identication of obligors under child support orders, detection of welfare fraud, processing background checks and tax
information or general employee information.
CERTIFICATION
I certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize the Medina
County Board of Commissioners, or its agents, to verify their accuracy and to obtain reference information on my work performance. I hereby
release the Medina County Board of Commissioners, from any/all liability of whatever kind and nature which, at any time, could result from
obtaining and having an employment decision based on such information. I understand that if this application is not completed in entirety, it will
not be processed and I will be automatically disqualied. I waive all provisions of law forbidding colleges or universities which I attended, or past
employers, from disclosing any information to the Medina County Human Resources Department, Department of Administrative services, and/
or the agency that holds the vacancy for which I am applying and to appropriate ofcials for recruitment purposes. 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.
If employed, I agree to engage in no outside activity which would involve a material conict of interest with, or which could reect adversely
on the Medina County Board of Commissioners, or each duly elected appointing authority. I further understand this decision rests solely with
the Board of Commissioners or with each duly elected appointing authority.
If employed, I agree to hold in strictest condence any information concerning the Medina County Board of Commissioners, the duly elected
appointing authorities, its Insureds, and its Agents that may come to my knowledge.
In consideration of my employment, if I am employed, I agree to conform to the employment policies of the Medina County Board of Commis-
sioners, or the duly elected appointing authorities, and understand that my employment and compensation can be terminated, with appropriate
notice, at any time, at their option or myself. I understand that completion of this Employment Application does not guarantee employment.
I hereby afrm that my answers to these statements and questions are true and correct to the best of my knowledge. I have not knowingly
withheld any facts or circumstance that would, if disclosed, affect my application unfavorably.
I understand that any misrepresentation, deception, or false statement made in this Employment Application may result in my not being con-
sidered for employment, and if not discovered until after my becoming employed, is grounds for, and may result in, my immediate termination.
I understand that I will be required to successfully complete a urinalysis for drug testing purposes and/or a blood alcohol test as a condition
of employment, as well as a criminal records background check as may be indicated by law. By submitting this Employment Application, I
hereby consent to either or both of said tests.
Medina County is an equal opportunity employer and does not discriminate against otherwise qualied applicants on the basis of
race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.
BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS.
APPLICANT SIGNATURE ________________________________________________________ DATE _____________________
INTERVIEWER’S NOTES: ________________________________________________________________________________________
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DO NOT WRITE IN THIS SPACE - FOR INTERNAL USE ONLY
c APPROVED
c DISAPPROVED c EDUCATION c EXPERIENCE c LATE c INCOMPLETE c OTHER _____________________
START DATE: ______________ STARTING RATE: _____________ PCN #: ____________ FUND NUMBER: __________________
DEPARTMENT HEAD SIGNATURE: __________________________________________________
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