Employment Application

Contact Information

1. First Name
2. Middle Name
3. Last Name
4. Address
5. City
6. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7. Zip
8. Phone
9. Email
10. Position applied for (1): Choose an open position. Public Health Nurse/Nursing Supervisor Seasonal Conservation Aide
11. Position applied for (2): Select One (Optional) Public Health Nurse/Nursing Supervisor Seasonal Conservation Aide
12. Date Available
13. Are you 18 or Older? Please Select Yes No
14. Do you have a legal right to work in the United States full-time? Please Select Yes No
15. Have you ever been employed by Iowa County? Please Select Yes No
Employed Start Date:
Employed End Date:
Employed Position
Reason for Leaving

Education

High School

16. Name and Location
17. Did you Graduate? Please Select Yes No No, but received GED

College or Trade School

18. Name and Location
19. Did you Graduate? Please Select Yes No
20. Major/Subject

Employment History

List employment from the past 10 years, starting with your most recent job. Account for any time period that you were unemployed by stating the nature of your activities.

Employer 1

21. Employer Name
22. Job Title
23. Address
24. City
25. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
26. Zip
27. Phone
28. Start Date
29. End Date
30. Current/Ending Pay
31. Supervisor Name
32. Work Performed
33. Reason For Leaving
34. Can we contact current employer? Please Select Yes No
Add Employer

Employer 2

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor Name

Work Performed

Reason For Leaving Add Employer

Employer 3

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor

Work Performed

Reason For Leaving

Additional Employers

Application Uploads

35. Resume
    only PDF files are allowed
36. Cover Letter
    only PDF files are allowed
37. Other Attachment
    only PDF files are allowed

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References

Please list three personal references, other than prior employers or relatives, whom we can contact.

Reference 1

38. Name:
39. Phone:
40. How long have you known this reference?
41. Occupation:

Reference 2

42. Name:
43. Phone:
44. How long have you known this reference?
45. Occupation:

Reference 3

46. Name:
47. Phone:
48. How long have you known this reference?
49. Occupation:

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Additional Information

50. Do you speak any languages other than English? Please Select Yes No
If yes, please list additional languages:

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51. List any professional, trade groups, organizations, machinery/tools operated in the past, and/or special skills that you consider relevant to your ability to perform this job.

    Chapter 35C of the Code of Iowa provides certain rights including preference in hiring if equally qualified to certain Veterans of United States Military Service. Qualification for these rights is defined in the statute.

52. Were you in the Military? Please Select Yes No
Branch
Do you have any experience from your military service that would be relevant to the job(s) for which you are applying? If yes, please explain:
Any person who may wish to claim a Veterans Preference must submit a copy of a certified form DD214 by the deadline set for the receipt of applications for the position for which the person is applying.
Upload DD214 Form
only PDF files are allowed

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53. Have you ever been convicted of a felony?
    For purposes of these questions, convicted includes plead guilty, plead no contest, or been given a deferred sentence of judgment. Please Select Yes No
If yes, please explain.
Note: A conviction will not automatically disqualify an applicant for a particular job and that the type and seriousness of the crime, the frequency of violoations, the date of conviction, and the applicant's entire work and educational history will be considered.

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Job Description

54. Have you read the job description? Please Select Yes No
55. Do you understand the requirements? Please Select Yes No
56. Can you perform the requirement of this job with or without reasonable accommodations? Please Select Yes No

Driver's License

57. If the job requires, do you have the appropriate valid driver's license? N/A Yes No
Driver's License #
License Type
State of License Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Have you had any moving violations? Please Describe:

Notices

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I hereby acknowledge that any employment relationships with Iowa County is of an At-Will nature, which means that the employee may resign at any time and that Iowa County may discharge at any time with or without cause. I understand that neither this document nor any offer of employment from Iowa County constitutes an employment contract unless a specific document to that effect is executed by Iowa County and me in writing.

In the event of employment, I understand that false or misleading information given in my application or interview(s) shall be considered sufficient cause for dismissal. I further understand that an incomplete application or an absence of my signature on this application is just cause for rejection of this application. I agree to employment entrance exams, if necessary, at Iowa County cost. I understand that I am required to abide by all rules and regulations of the employer.

Acknowledgment to Voluntarily Submit to Pre-Employment Physical and Drug Test

I, the undersigned, as a term of condition of possible employment with Iowa County hereby voluntarily consent to a Pre-Employment Physical Examination and Drug Test. I recognize my employment is dependent, among other things, upon passing all such tests to the exclusive satisfaction of Iowa County. Iowa County shall keep all results confidential recognizing that such information may be disseminated to certain individuals within the company needing to have such information.

Your Signature

58. Signature Please type your full name to serve as an electronic signature.
59. Today's Date

It is the policy of Iowa County to provide equal treatment to all Iowa County employees and applicants for Iowa County employment without regard to race, color, religion, political affiliation, creed, sex, sexual orientation, national origin or ancestry, age, mental or physical disability, marital status, except as bona fide occupational qualifications may require otherwise. This policy applies to all Human Resources actions and procedures including, but not limited to: recruitment, selection, training, compensation, benefit programs, promotion, demotion, transfer and termination of employment.