ST. JOSEPH COUNTY

APPLICATION FOR EMPLOYMENT

 

We consider applicants for all positions without regard to race, color, religion, creed, gender, national

origin, age, disability, marital or veteran status, or any other legally protected status.

 

PLEASE FILL OUT APPLICATION COMPLETELY

 

Position(s) Applying For:  

 

How were you referred to St. Joseph County?

 

 

Last Name   First Name   Middle Name

 

Present Address   

 

City    State   Zip Code 

 

Telephone Number    Alternate Telephone Number  Social Security # 

 

 

Best time to contact you at home is:

If you are under 18 years of age can you provide required proof of your eligibility to work?  YES NO

 

Have you ever filed an application with St. Joseph County before? YES NO

 

If yes, give a date (mm/dd/yyyy)

 

Have you ever been employed with St. Joseph County before? YES NO

 

If yes, give a date (mm/dd/yyyy)

 

Do any of your friends or relatives, other than spouse, work here? YES NO

If yes, state name, relationship and department.

 

(Family relationships may limit your placement in a department where a relative is employed.)

 

Are you currently employed? YES NO

 

Are you currently on "lay-off" status and subject to recall? YES NO

 

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? YES NO

 

(Proof of citizenship or immigration status will be required upon employment.)

 

Date available for work.

 

What is your desired salary range per year?

 

Are you available to work:  Full time      Please indicate shift: 1 2 3   

                                        

Please indicate: Mornings  Afternoons  Evenings  Temporary  

 

                        Part Time 

Please indicate dates available:

 

Have you been convicted of felony? Conviction will not necessarily disqualify an applicant from employment. YES NO

If Yes, please explain.

 

Have you ever been warned, disciplined or discharged for sexual harassment, fighting, assault ot related offenses? YES NO

If Yes, please explain.

 

Have you ever been warned, disciplined or discharged for violating safety rules? YES NO

 

If Yes, please explain.

EDUCATION

 

Name Address Course of Study Years Completed Date of Graduation Diploma/Degree



 

 

WORK EXPERIENCE

 

Start with your present or last job.  Include any job-related military service assignments and volunteer activities.

 

Name and Address of Employer

 From Date Position Held     

Reason For Leaving
To Date Supervisor's Name & Title 

Describe in Detail the Work You Did

Ending Salary

Name and Address of Employer

 From Date Position Held     

Reason For Leaving
To Date Supervisor's Name & Title 

Describe in Detail the Work You Did

Ending Salary

Name and Address of Employer

 From Date Position Held     

Reason For Leaving
To Date Supervisor's Name & Title 

Describe in Detail the Work You Did

Ending Salary

Name and Address of Employer

 From Date Position Held     

Reason For Leaving
To Date Supervisor's Name & Title 

Describe in Detail the Work You Did

Ending Salary

 

May we refer to your Previous Employers?  Yes  No  If No, Which Employer and why?

 

May we refer to your Present Employer?  Yes  No

 

SPECIALIZED SKILLS (Skills/Equipment Operated/Licenses)

List any appropriate knowledge or skills you may have relevant to your position interests.

 

    A.  Indicate clerical skills you possess and office equipment you can operate.

       

       

Please indicate Type of Equipment Operated and/or Software

 

    B.  Indicate trade skills you possess, machinery you can operate and other special technical capabilities.

 

 

    C.  Indicate any special professional and/or paraprofessional skills, knowledge or licenses you have.

 

 

 

Please answer the following questions if the position you are applying for requires a Commercial 

Driver's License or driving a motor vehicle.

 

Do you have a valid drivers license?  Yes  No

 

If Yes, what is the Driver's License Number?   State where it was issued

                          

Have you ever been convicted of or pled guilty to any traffic related offense within the last five years? 

Yes  No

 

Within the last five (5) years have you - had a license suspended or revoked?     Yes  No

 

 

Describe any specialized training, apprenticeship, job related skill, qualifications,

extra-curricular activities, or any job related training received in the United States Military.

 

 

 

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

 

 

State any additional information you feel may be helpful to us in considering your application.

 

 

 

Applicants Statement

 

I Certify that answers given herein are true, accurate and complete.

 

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an

employment decision. I release St. Joseph County and its representatives from any and all liability, claims or lawsuits in

regards to the investigation of all statements or information contained in this application for employment. 

 

This application for employment shall be considered for a period of time not to exceed 45 days. Any applicant wishing to be 

considered for employment beyond this time period should inquire as to whether or not applications are being accepted at

that time.

 

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with

St. Joseph County is of an "at will" nature which means that the Employee may resign at any time and the employer may 

discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship

may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by all 

members of the County Commissioners and County Council. I understand that receipt of this application by St. Joseph County 

does not imply employment and that this application and/or any other St. Joseph County documents are not contracts of

employment. 

 

In the event of employment, I understand that false or misleading statements or material omissions given in my application or 

interview(s) may result in the County's rejection of the application or immediate dismissal. I understand, also, that I am

required to abide by all rules and regulations of St. Joseph County. 

 

By submitting this application I acknowledge that I have read and understood the above statements and hereby authorize

 the company(s) listed in the references section of this application to release all records of past experience, including

assessments of my performance, ability, and fitness to Saint Joseph County. This includes specific authorization to provide

information on any alcohol tests with concentration result of 0.04 or greater, positive controlled substances test results, and

refusals to be tested as required by 49CFR 382.413. I hereby release this company(s) from any and all liability of any type

as a result of providing the above information to Saint Joseph County.

 

 

Thank you for completing this application and your interest in employment with St. Joseph County.

EQUAL OPPORTUNITY EMPLOYER