EMPLOYER 2: __________________________________________________________________________________________________
Company / Individual City, State
STARTING PAY: $_____________ ☐ HOUR ☐ SALARY ENDING PAY: $___________________ ☐ HOUR ☐ SALARY
JOB TITLE: _____________________________ RESPONSIBILITIES:______________________________________________________
REASON FOR LEAVING: _________________________________________________________________________________________
EMPLOYER 3: __________________________________________________________________________________________________
Company / Individual City, State
STARTING PAY: $_____________ ☐ HOUR ☐ SALARY ENDING PAY: $___________________ ☐ HOUR ☐ SALARY
JOB TITLE: _____________________________ RESPONSIBILITIES:______________________________________________________
REASON FOR LEAVING: _________________________________________________________________________________________
REFERENCES
(PROFESSIONAL ONLY)
FULL NAME: ___________________________________________________ RELATIONSHIP: _________________________________
First Last
E-MAIL: _______________________________________________________ PHONE: _________________________________________
FULL NAME: ___________________________________________________ RELATIONSHIP: _________________________________
First Last
E-MAIL: _______________________________________________________ PHONE: _________________________________________
FULL NAME: ___________________________________________________ RELATIONSHIP: _________________________________
First Last
E-MAIL: _______________________________________________________ PHONE: _________________________________________
The County of Delaware is an equal opportunity employer. The County of Delaware does not discriminate in employment on
account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual
orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service.
I understand that neither the completion of this application nor any other part of my consideration for employment establishes
any obligation for the County of Delaware to hire me. If I am hired, I understand that either the County of Delaware or I can
terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no
representative of the County of Delaware has the authority to make any assurance to the contrary.
I attest with my signature below that I have given to the County of Delaware true and complete information on this application.
No requested information has been concealed. I authorize the County of Delaware to contact references provided for
employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I
understand that this will constitute cause for the denial of employment or immediate dismissal.
Signature: ___________________________________________________ Date: _____________________________________________
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