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1 Revised: Feburary 2015 Y/Human Resources EMPLOYMENT APPLICATION Last Name First Name Middle Name/Initial Street and Number City County ( ) State Zip Phone Can your education and/or employment records be verified using the above name and social security number? Yes No If no, list other name(s): Name, address and phone number of person who will know where you may be contacted: ( ) Phone Please follow these general instructions: 1. Read the Examination/Position Announcement and be sure you meet, with or without reasonable accommodation, the “QUALIFICATIONS” listed. 2. Answer all questions and complete all spaces on the application. 3. Submit all transcripts and documents at the time of application. Position(s) applied for: How did you learn of the examination/position? Have you previously been employed by McLean County? Yes No If yes, from to Department Are you at least eighteen (18) years of age? Yes No Are you a U.S. citizen or an alien legally authorized to work in the United States? Yes No On what basis are you available for employment? (Check any or all that apply) Full time Part-time Summer Temporary Are you available for: Weekends and Holidays Yes Rotating Shifts Yes On Call Yes No No No Shift Preference (check any or all that apply): Days Evenings Nights Date available for work / Rate of pay expected $ per hour. 1. Have you ever been discharged or asked to resign from employment? Yes No 2. Do you object to an inquiry of you present employer in regard to your ability to work with others, work record, qualifications or abilities? Yes No If yes, explain: IF YOU HAVE ANSWERED “YES” TO ANY OF THE LAST TWO QUESTIONS, please give specifics on a separate sheet. A “yes” answer does not automatically disqualify you from employment. ---PAGE BREAK--- 2 Revised: Feburary 2015 Y/Human Resources Answer the four questions below if they are essential functions of the job for which you are applying. 1. Do you possess a valid Driver’s License? Yes No N/A 2. Do you possess a valid Commercial Drivers License Yes No N/A 3. Can you produce typed material (typewriter, computer, other)? Yes No N/A 4. Can you take notes verbatim (word for word) at a reasonable speed? Yes No N/A List any in-service training, instruction courses or programs you have completed: List any special information as to your work record you may deem of value: Are there any other experiences, skills or qualifications that you feel would especially fit you for work with McLean County and/or the position for which you are applying? If license, certificate or other authorization to practice a trade or profession is required for the position for which you are applying, complete the following: Name of trade or profession: License Number: Granted By: City and/or State of: Specialty: Licensed From: To: EDUCATION Name and Location Years Completed Diploma/Degree Course of Study High School 9 10 11 12 College 1 2 3 4 Graduate / Professional 1 2 3 4 Trade School 1 2 3 4 Describe your extra-curricular activities (e.g. professional/student organizations, leisure activities, civic, etc…): ---PAGE BREAK--- 3 Revised: Feburary 2015 Y/Human Resources EMPLOYMENT EXPERIENCE Start with your present or last job. Indicate any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disability or other protected status. 1. Employer Dates Employed From To Address Hourly Rate/Salary Work Performed: Starting: Telephone Final: Job Title Supervisor Reason for Leaving 2. Employer Dates Employed From To Address Hourly Rate/Salary Work Performed: Starting: Telephone Final: Job Title Supervisor Reason for Leaving 3. Employer Dates Employed From To Address Hourly Rate/Salary Work Performed: Starting: Telephone Final: Job Title Supervisor Reason for Leaving 4. Employer Dates Employed From To Address Hourly Rate/Salary Work Performed: Starting: Telephone Final: Job Title Supervisor Reason for Leaving ---PAGE BREAK--- 4 REFERENCES List three business/work references who are not related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are not related to you. 1. Name Relationship Years Acquainted ( Address Phone 2. Name Relationship Years Acquainted ( Address Phone 3. Name Relationship Years Acquainted ( Address Phone AGREEMENT I certify that the answers given herein are true and complete to the best of my knowledge I authorize McLean County to make such investigations and inquiries of my personal and employment history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of the County. Signature of Applicant Date NOTE: If you are applying for a position with the following departments, you will need to complete a form for purposes of a background investigation. Please ask for one of these forms. CIRCUIT CLERK SHERIFF’S DEPARTMENT COURT SERVICES FACILITIES MANAGEMENT PARKS AND RECREATION METRO McLEAN COUNTY COMBINED COMMUNICATIONS CENTER (METCOM) FOR OFFICE USE ONLY – DO NOT WRITE BELOW THIS LINE Application reviewed by: Name Date Name Date Name Date Name Date Name Date Name Date SIGN