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APPLICATION FOR EMPLOYMENT WAYNE COUNTY, OHIO An Equal Opportunity Employer ****************************************************************** DATE OF APPLICATION : ___________ POSITION(S) APPLIED FOR:______________________________________________________ STATUS OF POSITION APPLIED FOR: FULL-TIME PART-TIME OTHER REFERRAL SOURCE: ADVERTISMENT FRIEND RELATIVE EMP. AGENCY OTHER ****************************************************************** LAST NAME:_____________________________________________________________ FIRST NAME:______________________________________________M.I.____________ ADDRESS: __________________________________________________________________ CITY: __________________________________________ STATE: __ ZIP: _____ PHONE NUMBER: ___________SOCIAL SECURITY NUMBER: _________ ARE YOU AN ADULT, LEGALLY EMANCIPATED OR OTHERWISE LEGALLY ELIGIBLE TO WORK IN THE STATE OF OHIO? YES: NO: ARE YOU LEGALLY PERMITTED TO WORK IN THE UNITED STATES? YES: NO: HAVE YOU FILED AN APPLICATION WITH WAYNE COUNTY BEFORE? YES: NO: DATES: _________________________________ HAVE YOU BEEN EMPLOYED BY WAYNE COUNTY BEFORE? YES: NO: DATES:_________________________________ ARE YOU PRESENTLY ON LAYOFF AND SUBJECT TO RECALL? YES: NO:
DO ANY OF YOUR FRIENDS OR RELATIVES WORK FOR WAYNE COUNTY? YES: NO: If yes, list name(s):______________________________________________ HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES: NO: If yes, please explain: _____________________________________________ ________________________________________________________________ (The Employer will only consider specific crimes related to qualifications for position applied for.) DO YOU HAVE ANY COMMITMENTS (I.E., SECOND JOB, SCHOOL, ETC.) WHICH MIGHT INTERFERE WITH , OR ADVERSLY AFFECT, YOUR EMPLOYMENT SHOULD WE SELECT YOU FOR A POSITION. YES: NO: If yes, please explain: ________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ****************************************************************************** EMPLOYMENT HISTORY AND WORK EXPERIENCE In this section, list all employment history and work experiences in date order, including military experience. Begin with your current employer. Use additional paper if necessary. Failure to include all employment may be grounds for disqualification. ******************************************************************************* CURRENT EMPLOYER: __________________________________________________________ (Enter “none” if unemployed) MAY WE CONTACT YOUR CURRENT EMPLOYER PRIOR TO EMPLOYMENT? YES NO ADDRESS: ____________________________________________________________________ PHONE NUMBER: _______________ DATES EMPLOYED: ______________ TO____________ JOB TITLE: ____________________________________________________________________
SUPERVISOR’S NAME: __________________________________________________________ BEGINNING SALARY: _____________PER___________ ENDING SALARY: _____________PER___________ DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ WHY DO YOU WANT TO LEAVE? __________________________________________________ _____________________________________________________________________________ ****************************************************************** PREVIOUS EMPLOYER: _________________________________________________________ ADDRESS: ___________________________________________________________________ PHONE NUMBER: _______________ DATES EMPLOYED: ______________ TO____________ JOB TITLE: ____________________________________________________________________ SUPERVISOR’S NAME: __________________________________________________________ BEGINNING SALARY: _____________PER___________ ENDING SALARY: _____________PER___________ DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ WHY DID YOU LEAVE? __________________________________________________________ ******************************************************************
PREVIOUS EMPLOYER: _________________________________________________________ ADDRESS: ___________________________________________________________________ PHONE NUMBER: _______________ DATES EMPLOYED: ______________ TO____________ JOB TITLE: ____________________________________________________________________ SUPERVISOR’S NAME: __________________________________________________________ BEGINNING SALARY: _____________PER___________ ENDING SALARY: _____________PER___________ DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ WHY DID YOU LEAVE? __________________________________________________________ ****************************************************************** PREVIOUS EMPLOYER: _________________________________________________________ ADDRESS: ___________________________________________________________________ PHONE NUMBER: _______________ DATES EMPLOYED: ______________ TO____________ JOB TITLE: ____________________________________________________________________ SUPERVISOR’S NAME: __________________________________________________________ BEGINNING SALARY: _____________PER___________ ENDING SALARY: _____________PER___________ DESCRIBE YOUR DUTIES, RESPONSIBILITIES, EQUIPMENT OPERATED, PROMOTIONS, ETC.: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
WHY DID YOU LEAVE? __________________________________________________________ If you need to list any additional previous employers, please use a blank sheet of paper to do so. ****************************************************************** EDUCATION AND TRAINING This section is intended to give the Employer information about the education and training that the applicant has completed, and to demonstrate the skills, knowledge, and abilities of the applicant to perform the job duties of the position. ****************************************************************** HIGH SCHOOL ATTENDED: ___________________________________________ ADDRESS: ________________________________________________________ DID YOU GRADUATE HIGH SCHOOL? YES NO IF NO DO YOU HAVE A HIGH SCHOOL EQUIVALENT? YES NO COURSES COMPLETED PERTAINING TO JOB APPLIED FOR: ________________ ___________________________________________________________________ ACTIVITIES, AWARDS, ACHIEVEMENTS, ETC., RELATED TO THE POSITION APPLIED FOR: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ COLLEGE OR TRADE SCHOOL ATTENDED: _______________________________ ADDRESS: __________________________________________________________ DATES OF ATTENDANCE: ____________________TO______________________ DID YOU GRADUATE? _____________ DEGREE: ___________________________________
COURSES COMPLETED PERTAINING TO JOB APPLIED FOR: ________________ ___________________________________________________________________ ACTIVITIES, AWARDS, ACHIEVEMENTS, ETC., RELATED TO THE POSITION APPLIED FOR: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ GRADUATE SCHOOL(S) ATTENDED: _______________________________________________ _____________________________________________________________________________ ADDRESS: ___________________________________________________________________ DATES OF ATTENDANCE: ____________________TO______________________ DID YOU GRADUATE? ____________ DEGREE: ___________________________________ COURSES COMPLETED PERTAINING TO JOB APPLIED FOR: ________________ ___________________________________________________________________ ACTIVITIES, AWARDS, ACHIEVEMENTS, ETC., RELATED TO THE POSITION APPLIED FOR: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ****************************************************************** Please use the following space to provide any further information on training, education, skills, abilities, hobbies, volunteer work, etc., that you possess or have experienced that may be helpful in the evaluation of your application. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
****************************************************************** PLEASE LIST THREE REFERENCES WHO ARE NOT RELATED TO YOU THAT YOU HAVE KNOWN AT LEAST ONE YEAR: NAME: _________________________________________________________________ PHONE: ___________________ ADDRESS: ___________________________________ _______________________________________________________________________ NAME: _________________________________________________________________ PHONE: ___________________ ADDRESS: ___________________________________ _______________________________________________________________________ NAME: _________________________________________________________________ PHONE: ___________________ ADDRESS: ___________________________________ _______________________________________________________________________ ****************************************************************** Please answer the following questions if they are applicable to the position(s) for which you are applying. DO YOU POSSESS A VALID STATE OF OHIO DRIVER’S LICNESE? YES NO IF NO, CAN YOU OBTAIN ONE PRIOR TO EMPLOYMENT? YES NO DO YOU POSESS A VALID STATE OF OHIO COMMERCIAL DRIVERS LICENSE? YES NO IF YES, WHAT CLASS OF LICENSE? _______________________________________________ WHAT CDL ENDORSEMENTS?____________________________________________________ IF NO, CAN YOU OBTAIN THE PROPER CLASS OF COMMERCIAL DRIVER’S LICNESE AND ENDORSEMENTS, FOR THE POSITION YOU ARE APPLYING FOR, PRIOR TO EMPLOYMENT? YES NO
***************************** ************************************* Please read each of the following paragraphs carefully. Indicate your understanding of, and consent to, the contents and conditions of each by placing your initials at the end of each paragraph. If you have any ques tions regarding one or more paragraphs, contact the Employer before initialing. ****************************************************************** 1. I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any medical/psychological examination that the Employer deems necessary to determine whether I can perform the essential functions of the position, with reasonable accommodation when necessary. I understand and accept that this may include drug, alcohol, or substance abuse testing. Initials: 2. I understand and accept that given the duties and responsibilities of the Employer, I may be required to work weekends, evening hours, or at other times as determined by the Employer, including overtime hours. Initials: 3. I understand and accept that it may be necessary for me to sign waivers to allow the Employer to obtain information from my current and former employers, schools, and personal references. Initials: 4. I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that, if I am employed by the Employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded. Initials:
I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THIS EMPLOYMENT APPLICATION IS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I RECOGNIZE THAT MY FUTURE EMPLO YMENT WITH THE EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE, OR ALCOHOL ABUSE. I FURTHER UNDERSTAND THAT IF HIRED BY THE COUNTY, I MUST ABIDE BY ALL WAYNE COUNTY RULES AND REGULATIONS. Applicants Signature Date ****************************************************************** FOR PERSONNEL DEPARTMENT USE ONLY Arrange Interview Yes No Remarks Interviewer Date Employed Yes No Date of Employment Job Title Hourly Rate/Salary Department By: Name/Title Date * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *