Application For Employment

109 E. First Street Abilene, KS 67410

We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.

Completing an application does not imply that you will be interviewed or hired. If you are offered employment, it may be necessary to pass a physical examination and/or drug screen.

Name*

First NameMiddle NameLast Name

Date of Application*

Date

Home Street Address*

City*

State*

Zip*

Phone Number*

Email Address*

example@example.com

Date Available to Start?*

Date

Position Applied For*

Desired Salary*

Hourly or Yearly - Must be in dollar format (ex: $17.50 or $36,400)

Are you available to work*

Have you ever been employed with Dickinson County*

YesNo

If yes, list the department

Date Employment Started

Date

Date Employment Ended

Date

The reason for leaving

Are you related to anyone who works for Dickinson County?*

YesNo

If yes, please print their name, and their relationship to you

Are you legally eligible for employment in the United States? Proof of U.S. Citizenship or Immigration status is required upon employment*

YesNo

Have you received a disciplinary suspension or been discharged from any positions?*

YesNo

If yes. explain

Have you ever been convicted of a felony?*

YesNo

If yes, list when, where and nature of offenses

Are you currently employed?*

YesNo

May we contact your current employer

YesNo

Are you capable of performing, with or without a reasonable accommodation, the essential functions of the job for which you have applied?*

YesNo

Are you able to meet the attendance requirements?*

YesNo

Do you have a valid Driver's License if the job requires it?*

YesNo

Driver’s License Number

CDL Designation

Do you have your High School diploma or GED?*

YesNo

If no, what is the highest grade completed?

List Schools Attended: High School, College, Business, Technical, or Trade:*

	Name	Location	Credit Hours Earned	Type of Degree, Certificate, or Diploma	Major or Type of Training
School One
School Two
School Three
School Four

Licenses/Certificates

	License/Certification Issued By	Field/Trade	License/Cert No.	Issue Date	Date Expires

Skills and Qualifications: Summarize any special training, skills, licenses, certificates and/or characteristic ofyourself that may qualify you as being able to perform job-related functions for the position which you are applying.*

Did you serve in the military?*

YesNo

Branch

Rank at Discharge

From

Date

To

Date

Type of Discharge

If other than honorable, explain

Name*

Personal or Prefessional*

PersonalProfessional

How do you know your professional reference?

Phone*

Email*

example@example.com

Name*

Personal or Prefessional*

PersonalProfessional

How do you know your professional reference?

Phone*

Email*

example@example.com

Name*

Personal or Prefessional*

PersonalProfessional

How do you know your professional reference?

Phone*

Email*

example@example.com

Would you like to attach your resume?*

Yes - We will refer to your resume instead of requesting details about your past employers.No

Attach Resume

Employer’s Name

Kind of Business

Employer’s Address

Employer’s Phone Number

Your Job Title

From

Date

To

Date

Hours Per Week

Salary

Supervisor’s Name

Reason for Leaving

Duties

Employer’s Name

Kind of Business

Employer’s Address

Employer’s Phone Number

Your Job Title

From

Date

To

Date

Hours Per Week

Salary

Supervisor’s Name

Reason for Leaving

Duties

Employer’s Name

Kind of Business

Employer’s Address

Employer’s Phone Number

Your Job Title

From

Date

To

Date

Hours Per Week

Salary

Supervisor’s Name

Reason for Leaving

Duties

Employer’s Name

Kind of Business

Employer’s Address

Employer’s Phone Number

Your Job Title

From

Date

To

Date

Hours Per Week

Salary

Supervisor’s Name

Reason for Leaving

Duties

Please explain any gaps in your employment history*

I hereby authorize Dickinson County to contact, obtain and verify the accuracy of information contained in this application from all previous employers, educational institutions and references. I also hereby release from liability Dickinson County and its representatives for seeking, gathering and using such information to make employment decisions and all other persons or organizations for providing such information.

1 understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employmentand that this application does not constitute an agreement or contract for employment. Accordingly, either the employer or I can terminate the relationship al will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

The employer is an equal opportunity employer. The employer does not discriminate in employment, and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

I understand that Dickinson County will not refuse to hire a qualified individual with a disability because of that person’s need for an accommodation that would be required by the ADA. 1 understand that 1 may be asked to undergo a pre-employment physical examination and/or drug screen, and I authorize the release of any job-related

medical information from this examination/drug screen to Dickinson County. I understand that if this examination 'drug screen reveals the need for further examination, testing, or treatment, such further examination, testing, or treatment will be at my sole expense.

I understand my driving record may be reviewed, and I understand I may be required to complete any pertinent testing (i.e. typing, ten key. written exams, physical ability’ testing) prior to offer of employment.

Completing an application does not imply you will be interviewed or hired. If you are offered employment, it may be necessary to pass a background investigation, polygraph, physical examination and/or drug screen. Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodation to the application and or interview process should contact a Human Resources representative.

I also understand that if I am employed. I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I hereby represent that the information provided is correct and complete to the best of my knowledge. I understand that any incorrect, incomplete or false statements or information furnished by me may void this application or subject me to discharge any at any time after employment.

By typing your name, and signing below, you agree to the above disclaimer.*

First NameLast Name

Signature*

Date*

Date

Application For Employment

DICKINSON COUNTY

Personal Information

Education

Military Service (If Applicable)

References

Employment History

Past Employers

Disclaimer and Signature