Stanton County
Equal Employment Opportunity Employer

 

Application for Employment

This application is good for 180 days or until the position is filled.

 

Stanton County assures equal employment opportunity to applicants and employees in all aspects of personnel administration without regard to political affiliation, race, color, national origin, sex, age, marital status, pregnancy, mental or physical disability, genetic information, religion, military status, or any other prohibited basis of discrimination, as provided under applicable state and federal law.

 

FEDERAL LAW OBLIGATES US TO PROVIDE REASONABLE ACCOMMODATION TO THE KNOWN DISABILITIES OF APPLICANTS AND EMPLOYEES, UNLESS TO DO SO WOULD POSE AN UNDUE HARDSHIP.PLEASE FEEL FREE TO LET US KNOW IF YOU NEED AN ACCOMMODATION TO COMPLETE THE APPLICATION PROCESS OR TO PERFORM ANY ESSENTIAL ELEMENTS OF THE POSITION SOUGHT.

 

Type of Work Desired (CHECK ALL THAT APPLY):

Full-TimerPart-TimerRegularrTemporaryr

 

Have you ever been employed here before?††† r Yes†††† r No††† If yes, give date:____________________________________________________

Have you filed an application here before?††††† r Yes†††† r No††† If yes, give date:___________________________________________________

 

Applicant's Name (Last, First, Middle Initial):________________________________________________________________________________

Street Address:_______________________________________________________________________________________________________

City, State, Zip Code: __________________________________________________________________________________________________

Home Telephone Number:_______________________________ ††† Work Telephone Number:_________________________________________

Position Applied For:_________________________________ ††††† Date Available for Work __________________________________________

How did you learn about the job you have applied for? (Be specific as to the source.)_______________________________________________

 

Are you legally authorized to work in the United States?†† r Yesr No

If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration Reform and Control Act of 1986.While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired if you receive an offer of employment.

 

This position is subject to a veterans preference.Are you eligible for and requesting a veterans preference?†† r Yes

[A veteran requesting preference must submit with his/her Application for Employment a copy of the veteranís Department of Defense Form 214.A spouse of a veteran requesting preference must submit with his/her Application for employment a copy of the veteranís Department of Defense Form 214, a copy of the veteranís disability verification from the United States Department of Veteran Affairs demonstrating a 100 percent permanent disability rating, and proof of marriage to the veteran.]


 

EMPLOYMENT RECORD

List below the positions you have held, starting with your present employment.If more than one position or classification has been held with a given organization, list each position or classification as a separate period of employment.Under "Specific Duties," describe clearly the tasks you performed and the nature of your supervisory, technical, or other responsibilities.Please be complete.Your employment history may be verified by contacting previous employers.Volunteer, military, or unpaid experience will be evaluated in the same manner as paid employment and should be entered in the same manner.If you need more space, attach a separate sheet of paper.Please exclude organization names that indicate, for example, race, color, religion, sex, disability, or national origin.

 

Employment Information

Description of Duties

 

Employer/Kind of Business

 

 

Position Title

 

 

Street Address

 

 

Specific Duties

 

 

Immediate Supervisor/Title

 

 

Telephone Number

 

 

Dates of Employment (Month/Year)

From:†††††††††††††††††††††††††††††††††††††††††††† To:

 

Hourly Rate/Salary

Starting:††††††††††††††††††††††††††††††††††††††††† Final:

 

Part-Time†† rFull-Timer

 

Reason for Leaving

 

Employment Information

Description of Duties

 

Employer/Kind of Business

 

 

Position Title

 

 

Street Address

 

 

Specific Duties

 

 

Immediate Supervisor/Title

 

 

Telephone Number

 

 

Dates of Employment (Month/Year)

From:†††††††††††††††††††††††††††††††††††††††††††† To:

 

Hourly Rate/Salary

Starting:††††††††††††††††††††††††††††††††††††††††† Final:

 

Part-Time†† rFull-Timer

 

Reason for Leaving

 

Employment Information

Description of Duties

 

Employer/Kind of Business

 

 

Position Title

 

 

Street Address

 

 

Specific Duties

 

 

Immediate Supervisor/Title

 

 

Telephone Number

 

 

Dates of Employment (Month/Year)

From:†††††††††††††††††††††††††††††††††††††††††††† To:

 

Hourly Rate/Salary

Starting:††††††††††††††††††††††††††††††††††††††††† Final:

 

Part-Time†† rFull-Timer

 

Reason for Leaving

 


 

Employment Information

Description of Duties

 

Employer/Kind of Business

 

 

Position Title

 

 

Street Address

 

 

Specific Duties

 

 

Immediate Supervisor/Title

 

 

Telephone Number

 

 

Dates of Employment (Month/Year)

From:†††††††††††††††††††††††††††††††††††††††††††† To:

 

Hourly Rate/Salary

Starting:††††††††††††††††††††††††††††††††††††††††† Final:

 

Part-Time†† rFull-Timer

 

Reason for Leaving

 

 

EDUCATION/SKILLS RECORD

 

 

Please list education or specialized experience that relates to the position(s) for which you are applying.†† Exclude names or terms that indicate, for example, race, color, religion, sex, disability, or national origin.

Circle Highest Grade Completed:67891011 12

College:12345___††††† Did You Graduate?___Yes____No

 

 

 

Post- High School

Name of School

From

To

Major

Degree Type

College/University

 

 

 

 

 

Graduate School

 

 

 

 

 

 

If required by the job you have applied for, have you had training/course work or experience in (please check those that apply):

r Typing

rWord Processing

rData Entry

rPC/Computer Terminal

rCalculator/Adding Machine

rDictation Equipment

rShorthand/Speedwriting

 

Please list any other types of equipment you can operate or skills you possess, which you feel would be an asset in the position for which you are applying:____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

LICENSES AND CERTIFICATES

 

If a license, certificate, or other authorization to practice a trade or profession is required for the position for which you are applying, complete the following questions:

Name of Trade or Profession

License Number

Granted by

City and/or State

Specialty

Licensed††††††††††††††††††††††††† From:†††††††††††††††††† To:

 


 

APPLICANT'S STATEMENT

These answers are true and complete to the best of my knowledge.I understand that any false, omitted, or misleading information in connection with this application or during the interview process will result in rejection of my application or termination of my employment if I am hired, regardless of when discovered.

I also understand that any offer of employment may be conditioned upon a health evaluation by a doctor selected by the County to determine whether I can perform the job duties.In addition, I understand a drug or alcohol test may be required, depending upon County policy.I authorize the County to make a thorough investigation of my past employment, education, criminal history, job-related activities, and other relevant background information, and I release from all liability all persons, companies, and corporations providing such information, either in writing or orally.I also indemnify this County against any liability that might result from making such investigation.

Additionally, I authorize the County to supply my employment record, in its sole discretion, in whole or in part, to any prospective employer, government agency, or other party with an interest that the County deems appropriate.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create a contract between Stanton County and myself for either employment or for the providing of any benefit arising from employment.No promises regarding employment have been made to me.I understand that if an employment relationship is established, I have the right to terminate my employment at any time and Stanton County retains the same right, regardless of any oral representations to the contrary.Any changes in this ďat willĒ employment relationship must be made in writing and approved by the County Board.

 

 

SIGN HERE

 

 

 

 

Applicantís Signature (Use Ink)

 

Date

 

NOTE:UNSIGNED APPLICATIONS WILL NOT BE CONSIDERED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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