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(Including military experience, if job related. List employment beginning with present or last job)
Summarize special job-related skills and qualifications acquired from employment or other experience.
GREEN LAKE COUNTY
Affirmative Action Data Collection Self-Declaration
Race/Ethnic Group: (Please check the appropriate category)
Asian or Pacific Islander
American Indian or Alaskan Native
Have you been a member of the armed forces?
Vietnam Veteran's Era?
AUTHORIZATION & ACKNOWLEDGEMENT FOR EMPLOYMENT WITH GREEN LAKE COUNTY
You must agree to the following conditions in order to submit this application.
I certify that the answers given by me in this application are true and correct without omissions of any kind. I
understand that any misleading or incorrect statements may render this application void. If I am employed and
it is subsequently discovered that any answer given by me is incomplete, misleading or incorrect, I may be
terminated. I agree that Green Lake County shall not be held liable in any respect if my employment is
terminated because of false, incomplete or misleading statements, answers or omissions made by me in this
I also authorize pertinent companies, schools, agencies, municipalities or persons to give to Green Lake
County any information requested regarding my employment, character, experience and qualifications and/or
suitability for employment with Green Lake County including a check of my fingerprints and police record for
the purpose of considering my suitability for hire. I hereby forever release, discharge and covenant not to sue
any person or organization for any result of providing, obtaining or acting upon such information. I understand
that such information is sought with confidentiality and will not be released to me in any form whatsoever.
In addition, a copy of this authorization is as valid as the original and should be recognized as such.
I further understand that I must undergo a physical examination, including substance abuse screening, prior to
an appointment to a position with Green Lake County. Refusal to participate will result in the rejection of my
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