Personal Data

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Yes No   Yes No Yes No    Yes No    Newspaper. Please specify:
Employee of the County
Employment Agency
Green Lake County Website
Internet (Indeed, Handshake, LinkedIn, etc.) Please, specify:
Other. Please specify: Yes No Yes No Yes No Yes No
Yes No Yes No
Yes No
Employment Record

(Including military experience, if job related. List employment beginning with present or last job)

Special Skills and Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

List Education, Licenses, Certificates, and Degrees Related to the Position Sought
Institutions Attended
Degrees, Certificated Earned

Affirmative Action Data Collection Self-Declaration

The following information is requested to meet requirements for state and federal reporting. The data collected will be used for this purpose only. Submission of this data is voluntary. Responses remain strictly confidential and are filed separately from your application record. Green Lake County is an Equal Employment/Affirmative Action Employer and does not discriminate on the basis of sex, race, religion, color, national origin, age, physical condition or other protected status.

Race/Ethnic Group: (Please check the appropriate category)
White       Black       Hispanic       Asian or Pacific Islander       American Indian or Alaskan Native

Veteran Status:
Have you been a member of the armed forces?     Yes       No
Vietnam Veteran's Era?     Yes       No

Gender:     Female       Male

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 application.

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 application.