Download and save this form adding additional previous employers. Once filled out save and upload in the specified field below.

Position Sought *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

County *

SSN *

Social Security Number

Primary Phone Number *

Email Address *

Are you an Adult? *

• Yes
• No

Employment History and Work Experience

In this section, list all employment history and work experience in date order. Begin with your current employer. Failure to include all employment may be grounds for disqualification. Please fill out previous employers with the document above, then upload at the end of this online application

Current Employer

Enter “None” if unemployed

May we contact your current employer prior to employment?

• Yes
• No

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Dates Employed

Job Title

Supervisor's Name

Beginning Salary

Current Salary

Describe your Duties, Responsibilities, Equipment Operated, Promotions, etc…

Why do you want to leave?

Additional Previous Employers

Click or drag files to this area to upload.

You can upload up to 2 files.

Save, fill out, and upload the document above to show any additional previous employers.

Education and Training

This section is intended to give the employer information about the education and training that the applicant has completed, and to demonstrate the skills, knowledge, and abilities of the applicant to per form the job duties of the position.

High School Attended

Address of School

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Did you graduate?

• Yes
• No

High School Equivalent?

Courses pertaining to job applied for

Activities, Awards, Sports, Etc.

College or Trade School Attended

School Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Dates of Attendance

Did you graduate?

• Yes
• No

Degree

Courses Pertaining to job applied for

Activities, Awards, Sports, Etc.

Graduate School(s) Attended

Address of School

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Dates of Attendance

Did you Graduate?

• Yes
• No

Degree

Additional Education Information

Please use the following space to provide any further information on training, education, skills, abilities, hobbies, volunteer work, etc., that you possess or have experienced that may be helpful in the evaluation of your application.

Personal Information

Do you have any commitments (I.E., Second Job, School, etc.) which might interfere with, or adversely affect, your employment should we select your for a position?

• Yes
• No

If yes, please explain

Do you possess a valid Drviers License?

• Yes
• No

If no, can you obtain one prior to employment?

• Yes
• No

Are you eligible to work in the United States?

• Yes
• No

Are you a Resident of Ohio?

• Yes
• No

If not, are you willing to become a resident upon employment?

• Yes
• No

Are you related to anyone that iscurrently employed by the Seneca County Department of Job and Family Services?

• Yes
• No

References

Please list three references who are not related to you that you have known at least one year

Name of Reference 1

Phone Number

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Name of Reference 2

Phone Number

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Name of Reference 3

Phone Number

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

PLEASE READ EACH OF THE FOLLOWING PARAGRAPHS BELOW CAREFULLY

By checking this box and typing my name below, I am electronically signing this application and I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. *

• Acknowledgment

Typed Signature of Applicant *

Date *

Submit

IF YOU HAVE ANY QUESTIONS REGARDING THESE PARAGRAPHS, CONTACT THE EMPLOYER BEFORE SIGNING ABOVE.

1. I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any medical examination that the employer deems necessary to determine whether I can physically perform the essential functions of the position, with reasonable accommodation when necessary. I understand and accept that this may include drug, alcohol or substance abuse testing.
2. If employed, I understand and accept that, depending on the department in which I am applying for employment, I may be required to work evening shifts or night shifts, including weekends and be on call and work mandatory overtime hours.
3. I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded.
4. I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees. I also understand and accept that the various law enforcement and informational agencies that exchange information and data with the employer require that the employer’s employees do not have a past record of unlawful activities. Therefore, I understand and accept that, depending on the department in which I am applying for employment, it may be necessary for the employer to investigate my background for any criminal or unlawful activity.
5. I hereby authorize the employers, schools and personal references named in this application to provide information regarding me to the employer. I further authorize the release of personnel, academic and other records to the employer.

I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED THIS EMPLOYMENT APPLICATION IS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT ANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATION PROVIDED MAY LEAD TO WITHDRAWAL OF AN EMPLOYMENT OFFER OR TERMINATION FOLLOWING EMPLOYMENT. I ALSO RECOGNIZE THAT MY FUTURE EMPLOYMENT WITH THE EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE, OR ALCOHOL ABUSE. FINALLY, I AGREE THAT ANY CLAIM OR LAWSUIT RELATING TO MY SERVICE WITH SENECA COUNTY MUST BE FILED NO MORE THAN SIX (6) MONTHS AFTER THE DATE OF THE EMPLOYMENT ACTION THAT IS THE SUBJECT TO THE CLAIM OR LAWSUIT. I WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY.