Houghton County Employment Application Form

Houghton County Employment Application Form Please print all information requested except signature. APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS. PLEASE COMPLETE PAGES 1-4 Name 401 E. Houghton Ave. Houghton, Ml 49931 (906) 482-8307 Date __________ _ ------,Liet..,.,... __________ ..,,Rllt..,,....-------------,Miclclle...,,,..,....--- Present Address ---------------------------Number Sueet City State Zip Email How long at this address? __ _ --------------- Phone No. 0th er Phone ------------ ---------- Position Applied For: ________________ _ Salary Desired: __________________ _ Have you ever been employed here before? 0 Yes O No If yes, give date: ____ _ Employment desired: 0 FULL-TIME O PART-TIME O ANY AVAILABLE When are you available for work?_____ Can you travel if job requires it? O YES O NO Are you working now? 0 YES O NO Are you on a lay-off and subject to recall? O YES O NO May we contact your present employer? 0 YES O NO Are you prevented from lawfully becoming employed in the

country because of Visa or Immigration status? 0 YES O NO EDUCATION: Type of School Name of School Location Years Completed Major & Degree High School College Business or Trade Professional School HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE, (Misdemeanor or Felony)? • Yes • No If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. NOTE: A conviction record will not necessarily be a bar to employment. Factors such as age, time of offense, seriousness and nature of violation, and rehabilitation will be considered. SKILLS: Word Processing • Yes • No WPM: Personal Computer • Yes • No • PC • Mac REFERENCES: 10 Key • Yes • No Other Skills: Please list two references other than relatives or previous employers. Name Name Position Position Company Company Address Address Telephone Telephone An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying. HAVE YOU EVER BEEN IN THE ARMED FORCES? • Yes • No ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? • Yes • No Specialty Date Entered Discharge Date 2 WORK EXPERIENCE Please list your work experience beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets If necessa,y. Name of employer Name of last Employment dates Pay or salary supervisor Address City, State, Zip From Start Phone number To Final Your last job tiUe Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company. Name of employer Name of last Employment dates Pay or salary Address supervisor City, State, Zip From Start Phone number To Final Your last job title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company. Name of employer Name of last Employment dates Pay or salary Address supervisor City, State, Zip From Start Phone number To Final Your last job tiUe Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company. 3 AUTHORIZATION AND CERTIFICATION Please carefully read the following statements and initial each one where indicated. If you have a question regarding any of the statements, please ask prior to initialing and signing the application. Your initials and signature verify that you have read, understand, and agree to abide by the statements below. Initial: I hereby certify that all statements made on or in connection with my application are true, complete and correct to the best of my knowledge and belief, and I understand and agree that any misstatements or omissions of material fact subject me to disqualification or, if hired, dismissal. I authorize the County of Houghton to contact any of the persons or organizations referenced in my application materials. I also authorize any person contacted to provide to the County of Houghton any and all information regarding my employment, education, or any other information concerning any of the subjects covered by the application. I agree to execute employment records release authorization forms as may be required by the County of Houghton requesting employment records from my present and/or former employer(s). I understand that I may be required to successfully pass a physical and/or a drug test to gain employment or continue employment with the County of Houghton. I consent freely and voluntarily to participate in required test(s), at a location selected by the County of Houghton. I also consent to the release of the test(s) results to the County of Houghton. I hereby release and hold harmless the County of Houghton, its officers, agents, and employees, and the laboratory, their employees, agents and contractors from any liability whatsoever, except for their negligence, arising from the test(s) and decisions concerning employment based upon the results of this test(s). In addition, I understand that the County of Houghton maintains a drug-free and a smoke-free workplace. I understand that if certain positions have particular security requirements or if the County of Houghton determines there is a Bona Fide Occupational Qualification inherent in the position which requires certain information, a police background check seeking that information may be conducted prior to making a decision regarding employment. I authorize the County of Houghton, its officers, agents, and employees to conduct such a check if I am applying for one of these positions, and I release and hold harmless the County of Houghton, its officers, agents, and employees from any liability, except for its negligence, related to the performance or result of this check. If accepted for employment under a bargaining agreement, I agree that my status as an employee, depends upon successful performance during a probationary period and that I am an "at-will" employee during this probationary period. If accepted for employment not covered under a bargaining agreement, I understand that I will always be an "at- will" employee. Applicant's Signature Date Thank you for your interest in employment with the County of Houghton. AN EQUAL OPPORTUNITY EMPLOYER www.houghtoncounty.net