Perkins County Application for Employment

Full Name

First NameMiddle InitialLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

Position applied for:

Expected pay:

Would you accept full-time work?

Would you accept part-time work?

Available start date:

MonthDayYear

Do you have a valid driver's license?

Have you ever been employed by Perkins County?

Are you authorized to work and remain in the United States?

Were you ever discharged or forced to resign from any position?

Have you served in the U.S. Armed Forces?

Have you ever been convicted of any violation of the law? (Exclude traffic violations) A conviction will not necessarily disqualify an applicant from the position sought.

If Yes, Explain:

Are you a High School Graduate?

High School Equivalency?

Are you presently attending school?

Type of Education

Name of Instiution

Field of Study

Type of Degree

Did you Graduate?

Do you have additional education to enter?

Additional Type of Education

Name of Instiution

Field of Study

Type of Degree

Did you Graduate?

Type

Serial Number

Date Issued

Expiration Date

MonthDayYear

Typing Words Per Minute:

10 Key Speed:

Word Processing:

List Computer Background and Years of Experience:

Equipment Operated:

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Supervisor:

Ending Salary Per Month:

Date started

MonthDayYear

Date ended

MonthDayYear

Description of Duties:

Reason for Leaving:

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Supervisor:

Ending Salary Per Month:

Date started

MonthDayYear

Date ended

MonthDayYear

Description of Duties:

Reason for Leaving:

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Supervisor:

Ending Salary Per Month:

Date started

MonthDayYear

Date ended

MonthDayYear

Description of Duties:

Reason for Leaving:

Do you have additional employers to enter?

Name of Employer:

Job Title:

Phone Number

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Supervisor:

Ending Salary Per Month:

Date started

MonthDayYear

Date ended

MonthDayYear

Description of Duties:

Reason for Leaving:

Inquiry may be made of your current and former employers/schools you attended.

May we contact your present employer?

May we contact your former employers?

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business or Occupation

Phone Number

Area CodePhone Number

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business or Occupation

Phone Number

Area CodePhone Number

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Business or Occupation

Phone Number

Area CodePhone Number

APPLICANT’S STATEMENT AND AUTHORITY TO RELEASE INFORMATION

(Required for ALL Positions)

I understand that this employment application and any other county documents are not contracts of employment, and any person hired may be terminated by the employer at any time for any reason.

I understand that any oral or written statements to the contrary are expressly disavowed and should not be relied upon by a prospective or existing employee.

I understand that Perkins County may modify, change, or revoke any of its employment policies, pay practices, and benefits without my agreement.

I hereby state that all answers on this application are true and understand that falsifying this information can lead to termination if hired.

I hereby authorize any and all persons, companies, or agencies to release any and all background information, of a confidential or privileged nature, including criminal history, relevant to this application and any pertinent information they may have to the hiring authorities of Perkins County.

I release all such parties from all liability of every kind as the result of furnishing the same to Perkins County. This information is to be used to assist the county in determining my qualifications and fitness for the position I am seeking.

I hereby release Perkins County and its officers, agents and employees from any liability for the use of any and all of the foregoing information, in consideration for being reviewed for the aforesaid position.

I UNDERSTAND THAT IN ACCORDANCE WITH COUNTY POLICY, FINAL CANDIDATES ARE SUBJECT TO AN ALCOHOL / DRUG TEST AS A CONDITION OF EMPLOYMENT.

Should there be any questions regarding the validity of this release, you may contact me as indicated below.

Full Name

Date

MonthDayYear

How did you learn about this position?

Upload File

Upload a File

Perkins County Application for Employment

Education:

Professional License or Certificate, If Required

Skills

Employment History

Personal References

By entering your name and date below, you are signing this document.