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1. IMPORTANT: Read application carefully. Type or print this application using blue or black ink. 2. Complete the application in full. LATE, INCOMPLETE (including those that do not follow instructions) or UNSIGNED applications will not be considered. 3. Attach additional sheets and/or supplemental information as necessary or as required in the recruitment bulletin for the position. 4. If you have any questions, phone (406) 665-9735 or email OR 1. Name: Last name First name Middle Name 3. Mailing Address: City State Zip Code 4. Contact Numbers: Home: Mobile/Cell: 5. Email Address: Full-time Part-time Yes No Seasonal Intermittent 7. Date Available: Yes No 9. Are you a United States citizen or legally eligible for employment in the United States? (circle Yes No (If offered employment, you will be required to provide documentation to verify eligibility) Yes No Big Horn County Page 1 of 10 *The information contained on this form is sought in good faith. It will not be used in any way to discriminate against any applicant for employment in violation of state and federal law. P.O. Box 908 121 3rd St W, Hardin Hardin, MT 59034 5. Mail completed application to: Big Horn County Human Resources BIG HORN COUNTY 121 3rd Street West P.O. Box 908 Hardin, MT 59034 If yes, identify your relative(s) by name and relationship: 6. Type of Employment Desired (place X in the box of all that apply): 2. List other names, if any, that you have used in the past: PERSONAL INFORMATION 8. Are you 18 years or older? (circle) Full-time: at least 40 hrs. per week Part-time: less than 40 hrs. per week Intermittent: as needed, without regular schedule EMPLOYMENT APPLICATION An Equal Opportunity Employer* 3. Under state and federal law, qualified applicants with disabilities are entitled to reasonable accommodations. Modifications or adjustments may be provided to assist applicants to compete in the recruitment and selection process, to perform the essential duties of the job or to enjoy equal benefits and privileges of employment available to other employees. For the County to consider any such accommodation, the applicant must make known any needed accommodation. Must be completed Position applying for: Recruitment No.: Deliver completed application to: Big Horn County Courthouse Street Address or P.O. Box Human Resources Office, Room 302 (Third Floor) 10. Are you related to any person currently employed by Big Horn County? (circ All shifts? (circle) (including nights, weekends, holidays & rotating shifts) ---PAGE BREAK--- Have you ever been convicted of a felony? Yes No If yes, describe in full, giving dates: Yes No If yes, U.S. state of issue: Yes No If yes, specify: CDL Class: A B C CDL Type: 1 2 Date of first CDL: / / Other (specify): Yes No If yes, explain: School Course of Study Did you Graduate? (circle) List Degree or Certificate High School YES NO GED College/University YES NO College/University YES NO YES Other (Specify) NO YES NO Big Horn County Page 2 of 10 1 2 3 4 GENERAL INFORMATION 14. EDUCATION Last Year Completed (circle) 12. Driver License: Do you have a valid driver license? Endorsements (circle): 13. Have you ever been denied issuance of a driver license or have you ever had a license suspended or revoked? (circle) Air Brakes Hazardous Materials Tanker Doubles/Triples Passenger/School Bus Do you have a valid Commercial Driver License (CDL)? 15. List current professional licenses, registrations or certifications: (An affirmative answer will not automatically disqualify you from being considered as a candidate for employment) NOTE: If you have - or have had in the past three years - a driver license issued from a state other than Montana, attach a Motor Vehicle Driving Record report from the state the driver license was issued. Name and Address of School 1 2 3 4 1 2 3 4 11. CRIMINAL CONVICTIONS (An affirmative answer will not automatically disqualify you from being considered as a candidate for employment) ---PAGE BREAK--- Your Job Title: Phone Number: Full-time Part-time Volunteer Email Address: Describe your duties (including knowledge, skills, abilities required, employees you supervised, accomplishments): Your Job Title: Phone Number: Full-time Part-time Volunteer Email Address: Describe your duties (including knowledge, skills, abilities required, employees you supervised, accomplishments): Your Job Title: Phone Number: Full-time Part-time Volunteer Email Address: Describe your duties (including knowledge, skills, abilities required, employees you supervised, accomplishments): Big Horn County Page 3 of 10 1 Name & Complete Address of Employer We may contact the employers listed below, unless you indicate those employers you do not want us to contact. PLEASE DO NOT CONTACT (employer number(s) below): Reason(s): List your employment in reverse chronological order (begin with your present and/or most recent work experience) for at least the last seven years (include additional years if relevant to the job for which you are applying). Include military service and any volunteer work which has provided experience that would help you qualify. List each promotion as a separate position. List reasons for periods of unemployment. If you need additional space, continue on separate sheet(s) of paper using the format below. THE INFORMATION BELOW MUST BE COMPLETED EVEN IF A RESUME IS ATTACHED. Dates Employed: Immediate Supervisor: to Type of Business: 16. EMPLOYMENT HISTORY Immediate Supervisor: Dates Employed: to Reason for leaving: Type of Employment (circle): Type of Employment (circle): Reason for leaving: 2 Name & Complete Address of Employer Type of Business: Type of Employment (circle): Type of Business: Immediate Supervisor: Dates Employed: to Reason for leaving: 3 Name & Complete Address of Employer ---PAGE BREAK--- Your Job Title: Phone Number: Full-time Part-time Volunteer Email Address: Describe your duties (including knowledge, skills, abilities required, employees you supervised, accomplishments): Your Job Title: Phone Number: Full-time Part-time Volunteer Email Address: Describe your duties (including knowledge, skills, abilities required, employees you supervised, accomplishments): Your Job Title: Phone Number: Full-time Part-time Volunteer Email Address: Describe your duties (including knowledge, skills, abilities required, employees you supervised, accomplishments): Big Horn County Page 4 of 10 Type of Business: 4 Name & Complete Address of Employer Immediate Supervisor: Dates Employed: to Reason for leaving: 5 Name & Complete Address of Employer Type of Employment (circle): Type of Employment (circle): Reason for leaving: Type of Employment (circle): Reason for leaving: List other skills, education, experience and abilities relevant to the job for which you are applying (such as computer skills, equipment you know how to use, etc. May also list skills from volunteer work such as Habitat for Humanity or from professional organizations like Toastmasters): 17. KNOWLEDGE, SKILLS, EXPERIENCE AND ABILITIES Immediate Supervisor: Dates Employed: to 6 Name & Complete Address of Employer Type of Business: Immediate Supervisor: Dates Employed: to Type of Business: ---PAGE BREAK--- 1 2 3 Applicant Initials: Applicant Signature Date Big Horn County Page 5 of 10 Phone Number: 20. PLEASE READ THE FOLLOWING CAREFULLY, SIGN & DATE THE APPLICATION 18. REFERENCES List the names, addresses, email addresses and phone numbers of three persons who have knowledge of your experience, abilities and character as may relate to this job. Name: City, State, Zip: Email Address: Phone Number: Name: Address: Email Address: Address: Email Address: Phone Number: Name: Address: City, State, Zip: City, State, Zip: I am an applicant for a position with Big Horn County. As such, I am required to furnish information, which Big Horn County may use to determine my qualifications and suitability for employment. My signature below certifies that all information on this application and all attached pages are true, correct and complete to the best of my knowledge and contain no willful falsifications or misrepresentations. I understand that falsification, misrepresentation or omission of information is sufficient cause for rejection of this application and may disqualify me from consideration for employment with Big Horn County, or if hired, may be grounds for discharge (termination) from employment at a later date. I further understand that all information on this application is subject to verification and I consent to criminal history/driving background checks for applicable positions. I also consent that authorities of Big Horn County may contact my references, former employers, educational institutions or any other entities or agencies listed regarding this application. I further release said County, as well as my former employers, from any and all liability resulting from these reference checks. 19. BIG HORN COUNTY IS A DRUG & ALCOHOL-FREE WORKPLACE Big Horn County requires all employees to participate in Drug and Alcohol Testing. Employees will be tested for Pre- employment, Accident and Reasonable Suspicion. Employees required by Department of Transportation regulations are also randomly tested. I understand that these screening tests are required during my employment with the County. ---PAGE BREAK--- This page left intentionally blank Big Horn County Page 6 of 10 ---PAGE BREAK--- Applicant Signature Date OR A. B. C. D. E. Applicant Signature Date Big Horn County Page 7 of 10 I HEREBY CERTIFY that information provided above regarding my claim of preference is true and complete to the best of my knowledge. I am aware that falsification or misrepresentation is grounds for dismissal or disqualification from employment. I AM CLAIMING PREFERENCE 21. BIG HORN COUNTY EMPLOYMENT PREFERENCE FORM To claim preference as a qualified Veteran or Person with Disabilities, in accordance with Montana law, you must complete this form and return it with qualifying documents and your application by the posted closing date. A separate application must be completed for each position for which you wish to be considered. Providing the following information is voluntary, but must be included with the application in order to claim employment preference. This information will be kept confidential and will only be used during the hiring process. Contact the Big Horn County Human Resources Office for details on Veterans' preference. Contact your local Montana Vocational Rehabilitation Services Office, Department of Public Health and Human Services for details on obtaining Persons With Disabilities Preference certification. SIGN ONE BOX BELOW. I AM NOT CLAIMING PREFERENCE Disability Certification DD-214 showing the character of military discharge Service-connected disability letter 3. IF YOU CLAIM PREFERENCE, DOCUMENTATION MUST BE ATTACHED. Check which attachment(s) you included with this application: The mother of a veteran, if 1. THE VETERAN lost his or her life under honorable conditions while serving in the armed forces OR THE VETERAN has a service-connected, permanent and total disability, AND 2. YOUR SPOUSE is totally and permanently disabled, OR you are the unremarried widow of the father of department, OR you have received a Purple Heart. The spouse of a disabled veteran, if the veteran's disability prevents him/her from working. The unremarried surviving spouse of a veteran or disabled veteran. 1. To claim VETERANS' EMPLOYMENT PREFERENCE, you must be a U.S. Citizen and be (check one box below): A document issued by the Office of the Adjutant General of the Montana National Guard certifying service A Veteran, if 1. You have been separated under honorable conditions; AND you have served more than 180 consecutive days of active federal military duty, other than for training, in the Army, Air Force, Navy, Marines or Coast Guard OR were a member of the reserves who served on federal military duty during a period of war or in a campaign or expedition for which a campaign badge is authorized. 2. You are or have been a member of the Montana Army or Air National Guard who has satisfactorily completed a minimum of six years service in the armed forces, the last three of which have been served in the Montana Army or Air National Guard. A Disabled Veteran, if 1. You have been separated under honorable conditions from active duty, AND 2. You have an established, armed forces service-connected disability OR are receiving compensation, disability retirement benefits or pension from the U.S. Department of Veterans' Affairs or Military 2. To claim MONTANA PERSONS WITH DISABILITIES EMPLOYMENT PREFERENCE, you must be (check one box below): THE VETERAN. A person with a disability certified by OR The spouse of a totally (100%) disabled person certified by AND have resided continuously in Montana for at least one year immediately before applying for employment. ---PAGE BREAK--- This page left intentionally blank Big Horn County Page 8 of 10 ---PAGE BREAK--- Driving Record Request P.O. Box 201430, Helena, MT 59620-1430 • Phone (406) 444-3933 • Fax (406) 444-3816 • www.dojmt.qoy • [EMAIL REDACTED] Please PRINT. Ol'ftce Use 1. Requested Information (3J D A. Your Driving Record . 1:1 B. Another Person's Driving Record. Intended Use: To be completed if you checked B above . [lJ 0 For use by a federal, state, or local government agency, including a law enforcement agency or any individual acting on behalf of the agency in carrying out its functions. You must complete "Consent to Release Driving Record to Another Person or Entity" on next page. [2J 0 For use by a business or its agents, employees, or contractors in their normal course of business to verify the accuracy of personal information submitted by the individual to the business or it agents, employees, or contractors. If the submitted information is not correct or no longer correct, to obtain the correct information for the purposes of preventing fraud by pursuing legal remedies against or recovering on a debt or security interest against the individual. (4J D With written consent of the individual(s) who is the subject(s) of this search - The Personal Information Express Consent form on page two must be completed . [SJ 0 For use as part of a civil, criminal, administrative, or arbitrative proceeding in any court or government agency or before any self- regulatory body, including the service of process, an investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, pursuant to an order of any court. [6J D For use by an insurer, insurance support agency, or self-insured entity in connection with the investigation of claims, antifraud activities, ratemaking, or underwriting. [7J B For use by a licensed private investigator or security service for any purpose authorized under Montana law. [BJ For use by an employer or its agent to verify information related to a holder of a commercial driver license required under federal or Montana law. [9J D For use in providing notice to the owners of towed, abandoned, or impounded vehicles. [lOJ D For use by a parent of a child under 18 years of age. [llJ D For any other use that is specifically related to the operation of a motor vehicle or to public safety and is authorized under Montana law. Describe other use 2. Requestor Information Name of Requester: Lindsey Fox Employer/Company: (if applicable) Big Horn County Mailing Address: PO Box 908 City : Hardin State : MT Zip : 59034 Residential Address: 121 3rd St. w. City : Hardin State: MT Zip: 59034 Daytime Phone # : 4o5.e55•9735 Fax [PHONE REDACTED] Driver License XJOOOOOOOOO( State: MT 3. Search Information: This section must be complete. 4. Driving Records Fees Make checks payable to: Motor Vehicle Division Full Name: D Driving record=$4.12 per record D Certified driving record=$10.30 per record *cannot be faxed* Date of Birth: D Mail record=$3.09 extra per mailing (unless self- addressed, Driver License # : stamped envelope is included) D Fax record=$3.09 for the first five pages, $1.03 for each additional page (provide your fax number in section 2 above) Total - $ s. Certification I certify under penalty of law (MCA 45-7-203 Unsworn Falsification to Authorities) : . I have read the Montana Driver Privacy Protection Act, §61- 11-501 through 61-11-516, Montana Code Annotated, and understand that I can only use the information in this driving record for limited purposes. . I am the person listed as the requester . . If I am signing for an entity, the entity authorized me to do so . . The information I put on this form is true and correct to the best of my knowledge . Signature of requ.estor: Printed Name: Lindsey~ ~ Date: 06/21/2021 Montana county and state authorities reserve the right to reject any form that has been altered. 34-0100 18) This form is available in alternate formats for people with disabilities. ---PAGE BREAK--- Consent to Release Driving Record & Non-identifiable Personal Information Re uest P.O. Box 201430, Helena, MT 59620-1430 • Phone (406) 444-3933 • Fax (406) 444-3816 • www.dojmt.goy • DrjyerLjcense@mt,goy Please PRINT . This form authorizes the Department of Justice, Motor Vehicle Division, to release my driving record to another person or entity. Name on Driving Record: Driver License Date of Birth: Residing at: I hereby authorize the Department of Justice to release my driving record to the following individual or entity: Name: _ Address: r • t I certify under penalty of law (MCA 45-7-203 Unsworn Falsification to Authorities): • I have read the Montana Driver Protection Act,§ 61-11-501 through 61-11-516, Montana Code Annotated, and understand that I can only use the information in this driving record for limited purposes. • I am the person listed as the requester. • If I am signing for an entity, the entity authorized me to do so. • The information I put on this form is true and correct to the best of my knowledge. Signature: _ This is my legal signature Printed Name: Date: Montana county and state authorities reserve the right to reject any form that has been altered. 34-0lOOA 18) This form is available in alternate formats for people with disabilities.