POSITION APPLYING FOR (Please be specific)

NAME:
	Last	First	Middle	Previous Name

ADDRESS:
	Street & Number
	City	State	Zip Code

EMAIL ADDRESS:

Primary Telephone:

SOCIAL SECURITY NUMBER:

OHIO DRIVER´S LICENSE NUMBER:

Have you ever been employed by Clark County?	Yes No
If yes, please give date, department and reason for leaving:

Do you have any relatives employed by Clark County?	Yes No
If yes, please list name(s) and department(s):

Are you legally eligible to work in the United States?	Yes No
(Proof of legal authorization to work in the United States as required by the Immigration Reform and Control Act will be required upon employment)

Have you ever been convicted of a crime other than a minor traffic violation?	Yes No
If Yes, please explain:

 

EMPLOYMENT HISTORY

1. Employer’s Name:

Address:

Position Held:

To:

From:

Rate of Pay:

Reason for Leaving:

Supervisor’s Name:

Supervisor’s Phone Number:

May we contact your current employer?

Yes No

2. Employer’s Name:

Address:

Position Held:

To:

From:

Rate of Pay:

Reason for Leaving:

Supervisor’s Name:

Supervisor’s Phone Number:

3. Employer’s Name:

Address:

Position Held:

To:

From:

Rate of Pay:

Reason for Leaving:

Supervisor’s Name:

Supervisor’s Phone Number:

 

EDUCATIONAL HISTORY

High School:

Name and Location:

Graduated:

Yes No

Certificate:

 

College:

Name and Location:

Dates Attended:

to

Graduated:

Yes No

Degree:

Associate Bachelor Masters PhD

Certificate:

 

2nd College:

Name and Location:

Dates Attended:

to

Graduated:

Yes No

Degree:

Associate Bachelor Masters PhD

Certificate:

 

Training School:

Name and Location:

Dates Attended:

to

Graduated:

Yes No

Certificate:

 

Licenses:

In addition to your education, are there are other skills, qualifications, or experience we should consider:

 

REFERENCES

Below, please list the names, position and telephone numbers of three individuals, other than relatives, who we may contact for professional recommendations.

1.
	Name	Position	Phone
2.
	Name	Position	Phone
3.
	Name	Position	Phone

 

EMERGENCY INFORMATION

In the space provided below, please provide the name, address and telephone of one person who will always know your whereabouts. This information will be used only in case of an emergency.

Name	Relationship	Phone

 

ANNEXES

Please add PDF files only. Unable to convert your file into a PDF? Click Here to Download PrimoPDF to convert your Word or text documents into PDF's.

Resume:
Cover Letter:
Other:

 

CONSENT TO RELEASE RECORD INFORMATION

I declare that the statements made in this application (including statements made in any accompanying papers) have been examined by me and to the best of my knowledge and belief, are true and correct. I understand that any omission, misrepresentation and/or falsification of information contained in this application may constitute grounds for my dismissal. I hereby release all information relating to employment, educational, police, and medical records to Job & Family Services of Clark County. I give the employer the right to investigate all references and to secure additional job related information about me. Furthermore, I understand that I am free to resign at any time and that Job & Family Services reserves the right to terminate my employment at any time, subject to the procedures appropriate for the position or department. I understand that no one has the authority to make any assurance to the contrary.

I understand that if I am selected for employment with Job & Family Services, I may be offered a position conditionally pending a pre-employment physical and drug screening. I agree to undergo a physical examination, if required, and authorize the examining physician to render to the Human Resources Department the results of the examination. I further understand that any false statement or misrepresentation by me to the medical persons conducting the screening for Job & Family Services or on any of the medical history forms, or failure to complete or pass the screening, will be sufficient cause for cancellation of a job offer or dismissal from the County’s employment if I have been employed.

I give the employer the right to investigate all references and to contact all past employers and supervisors and to secure additional information about me, if job related including, but not limited to records relating to any criminal and civil convictions during the application period of at any time during my employment. I hereby release from liability Job & Family Services and its representatives for seeing such information and all other persons or organizations for furnishing such information. I further acknowledge that this document is a public document subject to the Ohio Public Records Act.

Signature (Your Name)	Date of Application

Type the code shown: