Stark County ND Employment Application Stark County is an Equal Opportunity Employer. Instructions: Please read all instructions carefully before completing your application. All questions must be answered completely and accurately. Incomplete applications will not be processed. If a question does not apply to you, enter “N/A”. Stark County does not discriminate on the basis of race, color, religion, sex, national origin, age or disability. Personal Information Date: _________ First Name: _________________________ Middle Name: _________________________ Last Name: _________________________ Address: ___________________________________ City: _________________________ State: __________ Zip: _____________ Home Phone: _________________________ Cell Phone: _________________________ Email: _________________________ Are you 18 years or older? Yes / No (If no, you may be required to provide authorization to work) Are you legally authorized to work in the United States? Yes / No Position Desired: _________________________ Date available to start: _________________________ Salary Desired: $_________________ per _________________ Type of employment desired: (Full-time, Part-time, Temporary, Seasonal, etc.) _________________________________________________________________________________ Are you related to any current Stark County Employee? Yes / No If Yes, please state name(s) and relationship: _______________________________________________________________________ Have you been employed by Stark County before? Yes / No If Yes, please state dates and Department: ____________________________________________________________________ Education History High School Name: _________________________________ City/State: _________________________ Did you Graduate? Yes / No If no, please list highest grade completed: _________________ College/University Name: ____________________________ City/State: _________________________ Did you Graduate? Yes / No Degree/Major: _________________________ Credits/Hours: _________________ Trade/Business/Other School Name: __________________ City/State: _________________________ Did you Graduate? Yes / No Degree/Major: _________________________ Credits/Hours: _________________ List any special skills or training: ____________________________________________________________________ Employment History List your last (3) employers, starting with the most recent. You may include up to five (5) years of employment history. You may attach a resume, but it will not substitute for completing this section. Employer 1: Company Name: ___________________________________ Phone: _________________________ Supervisor: ________________ Address: ___________________________________ City: _________________________ State: __________ Zip: _____________ Your Title/Position: _________________________ Start Date: _________________________ End Date: _________________ Hourly Rate/Salary: Start $_________________ End $_________________ Reason for Leaving: ____________________________________________________________________ May we contact this employer? Yes / No Employer 2: Company Name: ___________________________________ Phone: _________________________ Supervisor: ________________ Address: ___________________________________ City: _________________________ State: __________ Zip: _____________ Your Title/Position: _________________________ Start Date: _________________________ End Date: _________________ Hourly Rate/Salary: Start $_________________ End $_________________ Reason for Leaving: ____________________________________________________________________ May we contact this employer? Yes / No Employer 3: Company Name: ___________________________________ Phone: _________________________ Supervisor: ________________ Address: ___________________________________ City: _________________________ State: __________ Zip: _____________ Your Title/Position: _________________________ Start Date: _________________________ End Date: _________________ Hourly Rate/Salary: Start $_________________ End $_________________ Reason for Leaving: ____________________________________________________________________ May we contact this employer? Yes / No Certifications & Licenses Are you in possession of any certifications or licenses that are relevant to the position for which you are applying? Yes / No If Yes, please list (ex: CDL, EMT, RN, etc.) and expiration date: ____________________________________________________________________ ____________________________________________________________________ Professional References Please list three professional references. Do not include relatives. Reference 1: Name: _________________________ Phone: _________________________ Relationship: _________________________ Reference 2: Name: _________________________ Phone: _________________________ Relationship: _________________________ Reference 3: Name: _________________________ Phone: _________________________ Relationship: _________________________ Disclaimer and Signature I certify that the information provided in this employment application is true and complete to the best of my knowledge. I understand that any false statements or omissions may result in denial of employment or termination if discovered after hire. I authorize Stark County to verify all statements contained in this application and to conduct a background check, which may include criminal history, driving record, and credit history, as permitted by law. I release Stark County, its employees, and any third parties providing information from any and all liability arising from such investigation. I understand that this application does not create a contract of employment. If hired, my employment will be at-will, meaning either I or Stark County may terminate the employment relationship at any time, with or without cause or notice, unless otherwise provided by law or a written employment agreement. Signature: _________________________ Date: _________________________