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: Identication of obligors under child support orders, detection of welfare fraud, processing background checks and tax
information or general employee information.
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 disqualied. 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 ofcials 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 conict of interest with, or which could reect 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 condence 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 afrm 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 qualied 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: ________________________________________________________________________________________
DO NOT WRITE IN THIS SPACE - FOR INTERNAL USE ONLY
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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