Employment Application Form

Position Applying for:

DeputyJailerCivilian
Date Available for Employment*

MonthDayYear
Date
Name*

First NameLast Name
List any alias names used (i.e. maiden names, nicknames, etc.)*
Social Security Number*
Birth Date*

MonthDayYear
Place of Birth (City, State, Country)*
Sex at Birth*

MaleFemale
Phone Number*
Email
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you willing to work shift work? (nights, holidays, weekends, etc.)*

YesNo
Are you willing to wear a uniform?*

YesNo

Work History

Describe your work history BEGINNING WITH YOUR CURRENT OR MOST RECENT JOB. Complete all information requested.
Employer 1
Dates Employed *
Rate of Pay (Start and Finish)
Description of Duties*
Employer 2
Dates Employed *
Rate of Pay (Start and Finish)
Description of Duties*
Employer 3
Dates Employed *
Rate of Pay (Start and Finish)
Description of Duties*

Professional References

Please list five (5) work related references that we may contact. Include two (2) that are current or most recent supervisors.
Reference*
Reference*
Reference*
Reference
Reference
Personal References

Please list five (5) personal references that we may contact. List people you have known for at least four (4) years which are not former employers, relatives, or people with whom you are living.
Reference*
Reference*
Reference*
Reference*
Reference*

Drug Free Workplace Acknowledgement

The White County Government is a Drug Free Workplace. As a condition of employment with the White County Government, you will be required to submit to an alcohol and controlled substance screening test. In order to be employed by the White County Government, you must successfully pass this screening test. Candidates rejected for failing to pass the required screening will be required to wait at least 12 months before reapplying for employment. Employees who are indicted for, or convicted of, a controlled substance related violation under state or federal law, or who plead guilty or no contest to such charges must inform their Supervisor or Human Resources in writing within five days of the conviction or plead (this is a requirement of the Drug Free Workplace Act of 1988). Should you be offered a job with the White County Government, your position will be subject to post accident and reasonable suspicion testing. All safety sensitive positions will be subject to random drug and alcohol testing. These requirements are in accordance with the County's Substance Policy. By clicking here, you are acknowledging that you consent to such an examination and screening test.
I agree that I have read and agree with the above statement*

I Agree
Application Statement

By submitting this form, the submitter has applied for employment with the White County Government and herby authorizes the White County Government to contact current and former employers and references for the purpose of acquiring information regarding the applicant; furthermore authorizing such employers and references to supply such information verbally or in writing to the White County Government. In consideration for their furnishing such information, the submitter waives any and all claim against such former employers and references which may arise from their furnishing such information. The submitter/applicant understands that the White County Government has a Substance Abuse Prevention Program which includes drug testing. The submitter/applicant agrees to comply with applicable county policy. The submitter/applicant understands that once offered a position, the submitter/applicant will be required to complete drug screening. The submitter/applicant certifies that the answers given in this application are to the best of applicants knowledge and believe to be true and correct. The applicant further affirms that the applicant has not withheld any facts or circumstances that would detrimentally affect the application for employment, and understands that any misleading or incorrect statement may render this application void and would be cause for dismissal, if employed. Acknowledgement below certifies that the listed applicant and submitter of this form are same. Applicant agrees that: I AGREE THAT IF HIRED, THE WHITE COUNTY GOVERNMENT OR I MAY TERMINATE MY EMPLOYMENT AT ANY TIME WITH OR WITHOUT CAUSE. I UNDERSTAND THAT NO COUNTY POLICY, PRACTIVE, PROCEDURE, OR STATEMENT BY ANY COUNTY REPRESENTATIVE SHALL LIMIT OR ALTER THIS AT-WILL EMPLOYMENT RELATIONSHIP.
I agree that I have read and agree with the above statement*

I Agree
Birth Certificate File Upload

Upload birth certificate here. Only 1 file. Flies Allowed: jpg, pdf, png, doc, docx.
Cancelof
Diploma or GED Certificate Upload

Upload Diploma or GED here. Only 1 file. Flies Allowed: jpg, pdf, png, doc, docx.
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I acknowledge that the information I have provided is true and real to the best of my knowledge.
Signature*

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Date*

MonthDayYear
Date
Please verify that you are human*
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General Information

Work History

Employer 1

Employer 2

Employer 3

Drug Free Workplace Acknowledgement

Application Statement