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About your application… Thank you for your interest in employment with Otsego County. In order to provide high quality services to Otsego county residents, the County strives to hire the person best qualified for each position. Resumes and other documentation you wish to submit may be added, but resumes will not be accepted in lieu of a fully completed County application form. We expect that you will take the time to complete all areas of the application form and sign it. The information you provide will be verified. If there are omissions, falsifications or misrepresentations, we will have to withdraw your application from consideration. Should you start employment prior to the completion of the entire verification process, any falsifications or misrepresentations on the application will result in termination of your employment. Your application is a public record and can be viewed and/or copied upon request from any person.* *Pursuant to Freedom of Information Act 442 of 1976 Offers of employment are contingent upon the selected applicant passing any testing deemed necessary. Persons being hired by Otsego County will be checked for the following: Driver’s License verification Local, state and national criminal history record verification Verification of information on the application Background investigation with previous employers and others who can attest to your work habits, qualifications and character. Post-offer Physical Examination and Drug Screen Post-offer Examination If you have any questions, you may contact the Human Resources Office, Monday through Friday, from 8:00 a.m. to 4:30 p.m. ---PAGE BREAK--- EMPLOYMENT APPLICATION THE COUNTY OF OTSEGO IS AN EQUAL OPPORTUNITY EMPLOYER AND CONSIDERS APPLICANTS FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, AGE, RELIGION, SEX, NATIONAL ORIGIN, DISABILITY, MARITAL STATUS, HEIGHT, WEIGHT, MILITARY SERVICE OR ANY OTHER LEGALLY PROTECTED CLASSIFICATION IN ACCORD WITH STATE AND FEDERAL LAW. THE COUNTY ALSO REASONABLY ACCOMMODATES INDIVIDUALS WITH DISABILITIES AND BONA FIDE RELIGIOUS BELIEFS. THE COUNTY IS COMMITTED TO A DRUG-FREE WORKPLACE. PLEASE PRINT AND ANSWER ALL QUESTIONS, RESUMES ARE NOT ACCEPTED IN LIEU OF COMPLETION OF THE APPLICATION. IT IS IMPORTANT TO ANSWER ALL QUESTIONS; FAILURE TO COMPLETE ALL OF THE REQUIRED INFORMATION SHALL DISQUALIFY THE CANDIDATE FROM CONSIDERATION. POSITION APPLIED □ Full Time □ Part-time □ Seasonal Please specify days and/or hours available to work if Part-time or seasonal work is sought PERSONAL DATA: Last Name* First Middle *Is any additional information relative to a different name necessary to check your work record? □ yes □ no If yes, please explain or provide the different Street Address City State Zip Telephone Number Are you at least 18 years of age? □ yes □ no If under the age of 18, do you have working papers? □ yes □ no Are there any days, shifts or hours you will not work? □ yes □ no If yes, Date you will be able to start work? Are you willing to travel if your job requires? □ yes □ no Are you willing to work overtime if necessary? □ yes □ no Police Applicants: MCOLES Certified 2 ---PAGE BREAK--- Have you ever been convicted of a crime or pleaded guilty or “no contest” to a crime? □ yes □ no If yes, explain the nature of the offense and when and where you were convicted or pleaded guilty/no contest. Except for law enforcement positions, a conviction will not necessarily disqualify you and the information will be used for job- related purposes to the extent by law. Are you eligible to work in the United States and can you submit documentation verifying your eligibility? □ yes □ no Are you currently using illegal drugs? □ yes □ no Have you ever applied or worked here before? □ yes □ no If yes, provide dates List any relatives or friends currently employed here: Who should be contacted in the event of an emergency? Name Address Telephone Number Provide information below for all High Schools, Colleges, Universities, Trade or other schools you attended. Do not omit any institutions. EDUCATION: (May or may not be considered depending on the job applied for). Level Print Name, Address & Zip Grade completed or Degree(s) Subjects Studied or Major High School College Graduate Other Describe any educational degrees, skills, training, and proficiency in software programs or experience you believe are relevant to the job applied for: 3 ---PAGE BREAK--- EMPLOYMENT HISTORY: (Please complete for all full-time or part-time employment beginning with most recent employer). Copy this page as needed for additional employment information. Company Name: Telephone Number: Address: Dates Employed: From: To: Name of Supervisor: Pay rates: Starting: Ending: State Job Titles and Describe duties: Reason for leaving: Type of business: May we contact? □ yes □ no Company Name: Telephone Number: Address: Dates Employed: From: To: Name of Supervisor: Pay rates: Starting: Ending: State Job Titles and Describe duties: Reason for leaving: Type of business: May we contact? □ yes □ no Please explain any gaps in your employment history 4 ---PAGE BREAK--- EMPLOYMENT HISTORY (cont.) Company Name: Telephone Number: Address: Dates Employed: From: To: Name of Supervisor: Pay rates: Starting: Ending: State Job Titles and Describe duties: Reason for leaving: Type of business: May we contact? □ yes □ no Company Name: Telephone Number: Address: Dates Employed: From: To: Name of Supervisor: Pay rates: Starting: Ending: State Job Titles and Describe duties: Reason for leaving: Type of business: May we contact? □ yes □ no Please explain any gaps in your employment history 5 ---PAGE BREAK--- Have you ever been discharged or forced to resign? If yes, explain Did you receive any discipline in the last 12 months of active employment? If yes, explain Were you given a performance evaluation within the last 12 months of active employment? If yes, what was the range of scores used and what was your score? Have you signed or are you otherwise subject to any agreement with any other company that would limit or restrict the type of work you may perform for Otsego County? If so, please fully explain and provide a copy of the agreement upon request. MILITARY (Complete only if you served in the military) Branch and rank at discharge? Dates of service: To: Describe any military skills, training or experience you believe are relevant to the job applied for: DRIVING RECORD: (May or may not be considered depending on the job applied for) Do you have a valid Michigan driver’s license? □ yes □ no Commercial Driver’s License? □ yes □ no Have you had any tickets? □ yes □ no If yes, explain: Has your driver’s license ever been suspended or revoked? □ yes □ no If yes, explain: Do you have any DUI or DWI (drunk driving) convictions? □ yes □ no If yes, explain: 6 ---PAGE BREAK--- REFERENCES: Please list three Professional references. Professional (Past Employer) Name 1. Address City, State, Zip Telephone Number Professional (Past Employer) Name 2. Address City, State, Zip Telephone Number Professional Name 3. Address City, State, Zip Telephone Number 7 ---PAGE BREAK--- ACKNOWLEDGMENT (Please read carefully and sign below.) I authorize Otsego County and its agents to consult with and receive information from other companies, individuals, schools or agencies (public or private) concerning my employment, education, background, criminal or motor vehicle record, competence, experience, character or qualifications, and I authorize them to release such information to Otsego County as the County requests, including without limitation, my prior disciplinary record, without any obligation to give me written notice of such inquiry and/or disclosure. I also authorize Otsego County to release any information concerning my employment to any prospective or subsequent employers without any obligation to give me written notice of such disclosure. I authorize the Social Security Administration to verify that the Social Security number I will furnish is my assigned number and is valid for employment purposes. I hold harmless and release Otsego County and any individual, institution, company or agency from any liability as a result of the above inquiries and disclosures. I understand that this Application is not an offer or a contract of employment. If I am hired by Otsego County, I will be bound by the rules, policies, regulations, terms and conditions of employment of Otsego County as they may be communicated to me from time to time by the County and which may be changed or modified at the will of the County, in its sole discretion, with or without cause, or notice to me. I further understand and agree that Otsego County is an at-will employer which means that my employment relationship with Otsego County is for no definite period and subject to the express terms of any collective bargaining agreement covering my employment, may be terminated at any time, with or without cause, with or without notice, at the will of either Otsego County or me. I understand that the direction and control of all work is the sole prerogative of Otsego County and includes, by way of illustration only, the right to hire, layoff, transfer, reassign, demote or discharge. Only the Otsego County Board of Commissioners has the authority to enter into any agreement for employment for any specific period of time. I understand that according to federal law, I must produce documentation to verify my identity and authorization to work in the U.S. I agree that any employment with Otsego County is contingent on my ability to obtain and maintain the required documentation within the time period required by applicable law. I certify that all of the information in this Application (and other information given by me in support of my application) is true and complete. I understand that any misrepresentation, misleading statement or omission of any fact by me in this Application, in support of my application for employment, or during my employment, is sufficient reason for my not being offered employment or being disciplined, up to and including discharge, at any time during my employment in the sole discretion of Otsego County. I understand and agree that as a condition of employment, I may be required to undergo a post-offer medical examination, which includes a drug test. During any employment with the County, I understand that I may be required to submit to an alcohol or drug screening at the request of the County and I authorize the release of any such tests results to appropriate personnel of the Company. I further agree that during any employment with the County if I need an accommodation as the result of a disability, I will notify the appropriate Otsego County representative of my need for accommodation in writing within 182 days after I learn of the need. I acknowledge that this application will remain active for six months from this date. If I have not heard from the County at the conclusion of this six month period, it is my responsibility to complete a new application if I still wish to be considered for employment by the County. I agree that any claim or lawsuit relating to my application for employment, or service with Otsego County must be filed no more than six months after the date of the employment action(s) or event(s) that is the subject of my claim or lawsuit. I voluntarily and knowingly waive any statute of limitations to the contrary. Date: Print name: 8