Green Lake County Employment Application

Personal Data

Position Applied For

First Name

Middle Name

Last Name

Address

City

State

Zip Code

Phone Number

Alternate Number

E-mail Address

Upload Resume/Cover Letter

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1) Have you been known by another name? (If so, please indicate)
Yes No   

2) If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes No

3) Have you ever been employed with us before? (If yes, give date)
Yes No   

4) Have you ever filed an application with us before? (If yes, give date)
Yes No   

5) How did you find out about this job?
Local Newspaper       Internet     Job Service     Radio
Student Services      Other Newspaper

6) Are you currenlty employed?

Yes No

7) May we contact your employer?

Yes No

8) Are you prevented from lawfully becoming employed in this country because of VISA or immigration status? (Proof of citizenship or immigration status will be required upon employment)

Yes No

9) Have you ever had any job-related training in the United States Military? (If yes, please explain)
Yes No

10) Do you have any limitations which would required special accomodations for you to perform the essential functions/duties of the job for which you are applying? (If yes, please explain)
Yes No

11) Have you been convicted of a felony within the last seven years? (Conviction will not necessarily disquality an applicant from employment)

Yes No

12) Do you have any criminal charges pending, other than minor traffic violations, which relate to the job for which you are applying? (Pending criminal charges are not an automatic bar to employment. Each case is considered on its merits. If yes, please explain)
Yes No

13) Do you have the special licenses required for this position?
Yes No

Employment Record

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

Company Name		Special Duties
Phone
Address
City
State
Zip
Job Title		Reason for leaving
Supervisor
Date Employed
Starting Salary
Ending Salary

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Company Name		Special Duties
Phone
Address
City
State
Zip
Job Title		Reason for leaving
Supervisor
Date Employed
Starting Salary
Ending Salary

---

Company Name		Special Duties
Phone
Address
City
State
Zip
Job Title		Reason for leaving
Supervisor
Date Employed
Starting Salary
Ending Salary

---

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	Curriculum	Degrees, Certificated Earned

GREEN LAKE COUNTY 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

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 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.