Employment Application

Fill this in on screen, then print it to sign. Nothing you type is sent anywhere — the form works entirely in your browser, so nothing is saved if you close the page. If you would rather write it out by hand, print the blank pages first. Your Social Security number and your signature are left blank on purpose: write them on the printed copy.

Pickaway County, Ohio

An equal opportunity employer

Application for Employment

Social Security number (write this on the printed copy)

Employment history and work experience

In this section, list all employment history and work experience in date order, including military experience. Begin with your current employer. Failure to include all employment may be grounds for disqualification.

Current employer

May we contact your current employer prior to employment?

Previous employer

Previous employer

Previous employer

Previous employer

Education

This section is intended to provide information about the education and training that you have completed and to demonstrate the skills, knowledge, and abilities you possess to perform the job duties of this position.

High school

Post-secondary education

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 you for a position?

Do you possess a valid driver’s license?
If no, can you obtain one prior to employment?
Are you eligible to work in the United States?
Are you a resident of Pickaway County?
If not, are you willing to become a resident upon employment?

References

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

Reference 1

Reference 2

Reference 3

Acknowledgments

Initial each statement below.

I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing a 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.

If employed, I understand and accept that I may be required to work evenings, nights and/or weekend days.

I understand and accept that if any information required on 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.

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 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 it may be necessary for the employer to investigate my background for any unlawful activity.

I confirm that all of the information furnished in 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 any employment offer or termination following employment. I recognize that my future employment with the employer will be jeopardized if I engage in substance abuse, illegal drug use or alcohol abuse.

Applicant’s signature (sign after printing)

EEO data: voluntary disclosure form

Regulations of the Equal Employment Opportunity Commission (EEOC) require employers to compile data regarding the nature and make-up of their work forces in order to further the goals of Title VII of the Civil Rights Act of 1964, as amended. Your responses to the following questions will help the employer comply with this requirement. Completion of this questionnaire is entirely voluntary on your part. Should you opt to complete the questionnaire, your response will be used by the employer solely for the purposes of preparing the reports required by the EEOC. Your response will be kept confidential and will play no part in the employer’s evaluation of your employment performance or status, or your treatment as an employee. The completed questionnaire will be kept separate from your personnel file.

Racial and ethnic categories
County use only

Do not write below this line.

Hired (yes / no)

Position

Dept.

Salary / wage

Date reporting to work

Shift

Sign and date the printed copy, add your Social Security number, then deliver or mail it to the Pickaway County Commissioners, 139 West Franklin Street, Circleville, Ohio 43113.