FREMONT COUNTY GOVERNMENT
APPLICATION FOR EMPLOYMENT
(Please Type or Print)
NAME: __________________________________________________________ DATE: _________________
Last First Middle
MAILING ADDRESS: ______________________________________________________________________
Street City State Zip
TELEPHONE (Daytime) ____________ (Evening) ____________ E-Mail Address ______________________
Are
you 18 years of age or older? Yes No Do you have a valid
driver’s license? Yes No
Driver’s License Number: _________________________
CDL Number (if applicable)_________________ Type:_____
If
hired, can you provide written evidence that you are authorized to work in the
U.S.? Yes No
Job Title:_________________________________________ Part time or Full time: ____________________
EDUCATION
Type Name/Location No. years completed Degree/Diploma
High School:
________________________________________________________________________________________
College:
________________________________________________________________________________________
Vocational Training – Other
EMPLOYMENT RECORD (start with current/most recent)
Company Name/Address/Phone Type of Work Employment Dates Reason for Leaving
May
we contact your current employer? Yes No
1
_________________________________________________________________________________________________
2
_________________________________________________________________________________________________
3
_________________________________________________________________________________________________
4
Is
there any information we would need regarding your name, or use of another name,
for us to be able to check your work record? Yes No If yes, please
specify: ____________________________________________
Please list any additional information that relates to your ability to perform the job for which you have applied – such as licenses, professional memberships, hobbies, etc.:________________________________________________________
WORK RELATED REFERENCES
Name Occupation Address/Phone Years Known
1
_________________________________________________________________________________________________
2
_________________________________________________________________________________________________
3
_________________________________________________________________________________________________
4
APPLICANT’S STATEMENT
I understand that the employer follows an “employment at will” policy, in that the employer or I may terminate my employment at any time, or for any reason consistent with applicable state or federal law. I understand that this application is not a contract of employment.
I understand this application will be active for a period of three (3) months; after that time, if I wish to be considered for employment, I must submit a new application.
I understand that the employer will thoroughly investigate my work and personal history and verify all data given on this application, on related papers and interviews. I authorize all individuals, schools and firms named therein, except my current employer if so noted, to provide any information requested about me, and I release them from all liability for damage in providing this information. This information will be kept in strict confidence and will be available only to agency personnel who are involved in the hiring decision.
I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.
Signature: ___________________________________________________ Date: ______________________
Fremont County employs people on the basis of their qualifications and with assurance of equal opportunity and treatment, regardless of race, creed, religion, color, sex, age, national origin, ancestry or disability.