Pottawatomie County Application For Employment

Personal Information

 

Name: ______________________________________________________    Social Security No: _______________

                      Last                          First                        Middle            

 

Present Address: ________________________________________________________________________________

                                    Street                                          City                                 State                        Zip

 

Permanent Address:______________________________________________________________________________

                                   Street                                          City                                 State                        Zip

Are You 18 Years or Older?   Yes   No              Phone No:                        Apartment No:

In Case of 

Emergency Notify: _______________________________________________________________________________

                                          Name                                      Address                                            Phone 

Are you prevented from lawfully becoming employed in this country because 

of visa or immigration status ?            Yes    No                                                                                                                                                                     

Employment Desired

Position:                                                         Date You Can Start:                      Salary Desired:  
Are You Employed Now?     Yes   No      If so May We Inquire of Your Present Employer ?  Yes   No 
Ever Applied Here Before?  Yes   No               Where?                                        When?
Ever Worked Here Before?  Yes   No               Where?                                        When?
Reason For Leaving: 
Who referred You to This Company?       Newspaper            Pottawatomie County Website           Other

Education

School Level Name & Location of School  No. of Years Attended Date Graduated Subjects Studied
Grammar School 

 

        
High School

 

        
College

 

        
Trade School

 

        

General

Subjects of Special Study or Research Work:

 

Special  Training:

 

Special Skills:

 

 

 

Former Employers

Name & Address of Present or Last Employer:

 

                                                                         

Starting Date: ______________________(Month/Year)      Leaving Date: _______________________(Month/Year)
Weekly Starting Salary:                                                  Weekly Ending Salary:
Job Title:                                                                        May We Contact Your Supervisor?    Yes   No
Name & Title of Supervisor:                                                                                   Phone No:

Description of Work:

 
Reason for Leaving:

Name & Address of Present or Last Employer:

 

                                                                         

Starting Date: ______________________(Month/Year)      Leaving Date: _______________________(Month/Year)
Weekly Starting Salary:                                                  Weekly Ending Salary:
Job Title:                                                                        May We Contact Your Supervisor?    Yes   No
Name & Title of Supervisor:                                                                                   Phone No:

Description of Work:

 
Reason for Leaving:

Name & Address of Present or Last Employer:

 

                                                                         

Starting Date: ______________________(Month/Year)      Leaving Date: _______________________(Month/Year)
Weekly Starting Salary:                                                  Weekly Ending Salary:
Job Title:                                                                        May We Contact Your Supervisor?    Yes   No
Name & Title of Supervisor:                                                                                   Phone No:

Description of Work:

 
Reason for Leaving:

References 

Please give the names of three persons not related to you, whom you have known at least one year.

Name  Address Business Phone & Email Years Acquainted

1. 

 

 

 

 

 

  

 

2.

 

 

 

 

 

  

 

3.

 

 

 

 

 

  

 

Service Record

Branch of Service:                                  Discharge Date:                         Discharge Rank:                       
Present Membership in National Guard or Reserves  Yes   No             Date Obligation Ends:

Special Questions

Have you been convicted of a felony or misdemeanor within the last 5 years?    Yes   No  

                                                             Describe:

Authorization

I certify that all the information submitted by me on this application is true and complete, and I understand that if

any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I 

am employed, my employment mat be terminated at any time.

 

In consideration of my employment, I agree to conform to the company's rules and regulations. I also agree 

to follow any additional departmental rules and regulations. I acknowledge and agree that employment with the county is at will and I shall not consider any employment offer as a contract. I agree that my employment and compensation may be terminated, with or without cause, and with or without notice, at any time, either at my or 

the County's option. I understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice at any time by the County.

 

Date: _______________     Signature: ___________________________________________________