Fillable MUSKINGUM COUNTY APPLICATION FOR EMPLOYMENT (Muskingum County Commissioners)

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MUSKINGUM COUNTY APPLICATION FOR EMPLOYMENT (Muskingum County Commissioners)

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MUSKINGUM COUNTY
APPLICATION FOR EMPLOYMENT
Muskingum County is an equal employment opportunity employer and complies with the Civil Rights Act, the
Americans With Disabilities Act and other legislation which prohibits discrimination in employment because of
race, color, creed, gender, religion, national origin, age, disability, marital or veteran status, or any other legally
protected status. Any applicant, who feels that he or she has been discriminated against in some manner, is
encouraged to report the incident immediately to the Human Resources Director or Appointing Authority. Please
note that this completed form will become a public record when submitted to the County.
Instructions: Your interest in employment with our County is appreciated. This application is the initial step in
the selection process and it will help the County assess your qualifications, work history, experience and
training. You must complete this application, in full, to be considered for employment. If you have a resume, you
may attach it to this application form, however, you must still complete this application form. If there is
insufficient space available to adequately provide the information requested, you may use an additional paper
and attach it to the back of this form. Please write legibly.
If you need assistance completing this form because of a disability, please request that the official provide
someone to assist or you may request some other reasonable accommodation.
DATE OF APPLICATION: ____________________
PERSONAL INFORMATION
Name ________________
____________________________________________________________________________________
Last First Middle
Telephone # ( ) __________-________________ Mobile/Other # ( ) __________-___________________
Current Address ___________________________________________________________________________________________
Number Street City Zip Code
E-mail ___________________________________________________________________________________________
Are you legally eligible for employment in the United States? Yes □ No □
If you are under 18, can you furnish a work permit? Yes □ No □
Have you ever been employed by Muskingum County? Yes □ No □
If yes, which department?
Do you h
ave any secondary employment that will continue if you are hired by the County?
Yes
□
No □
If yes, list the nature of the secondary employment
_____________________
_____________________________________________________________________
EMPLOYMENT HISTORY
Start with present or most recent employer
Employer:
Phone No.
Address:
Job Title:
Salary:
Supervisor Name:
Starting $ ___________ Last $___________ Dates employed: ___________ to ____________
Position/Duties:
Reason for leaving:
May we contact for a job reference?
Employer:
Phone No.
Address:
Job Title:
Salary:
Supervisor Name:
Starting $ ____________Last $____________ Dates employed: __________ to ____________
Position/Duties:
Reason for leaving:
May we contact for a job reference?
□ Yes □ No
Employer:
Phone No.
Address:
Job Title:
Salary:
Supervisor Name:
Starting $ ___________ Last $____________ Dates employed: ___________to ____________
Position/Duties:
Reason for leaving:
May we contact for a job reference?
□ Yes □ No
Please explain any gaps in Employment:
_______________________________________________________________________________________________
Have you ever been fired or asked to resign from a job? Yes □ No□
If yes, please explain:
EDUCATION AND TRAINING
NAME/ADDRESS OF
SCHOOL
COURSE OF
STUDY
YEARS
COMPLETED
DIPLOMA/DEGREE
OBTAINED
High School
Undergraduate
College
Graduate
Professional
Other (specify)
Describe courses or the training you’ve received which you feel will help you perform the job for which you are
applying.
RELATED INFORMATION: Please list any relevant professional or trade organizations of which you are a
member. Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age,
mental or physical disability, veteran/reserve National Guard or any other similarly protected status.
ORGANIZATION
OFFICES HELD
ABOUT THE JOB YOU ARE APPLYING FOR
Please review the position posting/description so that you understand particularly the essential duties and
qualifications for the job. Proceed in answering the remainder of questions on this application form. A copy of
the complete job description is available upon request.
Position you are applying for:
How did you hear about the position? □ Website □ Bulletin Board □ Employee □ Friend/Relative □ Other
Can you perform the essential functions of the job (with or without a reasonable
accommodation)?
Yes □ No □
If no, please describe:
Do you feel that you will need additio
nal training in any areas to effectively perform the job?
Yes □ No □
If yes, please explain:
Expected Hourly Rate: $______________
Type of employment
interested in:
Full-time □ Part-time □ Any □
Seasonal □ Intermittent □
Date available to work? __________________
List any schedule
restrictions
List all job equipment (listed on the description) which you are qualified to operate
REFERENCES
Please provide the names and telephone numbers of three professional references who are not related to you
and are not previous supervisors. If professional references are not available, provide school or personal
references who are not related to you.
NAME
TITLE
RELATIONSHIP
TELEPHONE #
APPLICANT STATEMENT AND SIGNATURE
I certify that all information I have provided in order to apply for and obtain employment with Muskingum County is true,
complete, and correct. I agree and understand that omissions, misstatements, and falsifications will cause forfeiture on my
part of all eligibility for any employment with Muskingum County and may be cause for rejection of this application,
removal of my name from eligibility lists, or discharge from County service, whenever it is discovered. I give Muskingum
County the right to investigate and verify any information obtained through the application process. Permission is granted
and I release from any and all liability any employer, agency or individual assisting Muskingum County in providing
relevant, job-related information that will assist in this process. I expressly authorize, without reservation, Muskingum
County, its representatives, members or agents to contact and obtain information from all references (personal and
professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the
accuracy of all information provided by me in this application. I hereby waive any and all rights and claims I may have
regarding Muskingum County, its agents, members or representatives, for seeking, gathering, and using such information
and all other persons, corporations, or organizations for furnishing such information about me. I understand that an offer
of employment may be contingent upon the successful completion of a pre-employment background criminal
investigation, physical, psychological, polygraph, and/or drug and alcohol screen. If employed, I agree to provide proof of
identity, relevant licensure or credentials, and authorization for employment in the United States. If I am hired, I
understand that, unless otherwise defined by applicable law, any employment relationship with Muskingum County is of
an “at will” nature, which means that I am free to resign at any time and Muskingum County reserves the same right to
terminate my employment at any time. This application does not constitute an agreement or contract for employment for
any specified period or definite duration. I understand that all conditions of employment including, but not limited to hours,
benefits and salary are subject to change by Muskingum County at any time. I understand that no representative of
Muskingum County is authorized to make any assurances to the contrary and that no implied, oral or written agreements
contrary to the foregoing express language are valid unless they are in writing and signed by the appropriate Appointing
Authority.
DO NOT SI
GN UNTIL YOU READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement.
______________________________________________________________________________________
Applicant’s Signature
_____________________
Date
Form Date: June 2017
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MUSKINGUM COUNTY APPLICATION FOR EMPLOYMENT (Muskingum County Commissioners)

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Completed 20 July 2020

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