Section I - Personal Information Name: Street Address: City, State, Zip: County: Home Phone: Work Phone: Are you at least 18 years old? Yes No If under 18, can you obtain a work permit? Yes No Are you a citizen of the United States? Yes No Do you have any physicial, mental or medical impairment that will interefere with your ability to perform the job for which you are applying? Yes No If yes, please explain: Section II - Work Preferences Please describe in one or two sentences the type or nature of work you are looking for: Do you need: Full Time Work Part Time Work Are you interested in: Permanent Work Temporary Work Intermittent Work Seasonal Work No Preference What is your minimum salary requirement? Date available to start: Section III - Work Experience Please describe your work experience (be sure to include United States military experience or prior public service work) by completing the spaces on this section. Begin with your most recent employer. May we contact these employers for references? Yes No Employer's Name: Street Address: Supervisor's Name: Dates Employed: Job Title, Beginning and Ending: Salary, Beginning and Ending: Describe your duties, responsibilities, equipment operated, etc. for position(s) held: Describe your reason(s) for leaving: Employer's Name: Street Address: Supervisor's Name: Dates Employed: Job Title, Beginning and Ending: Salary, Beginning and Ending: Describe your duties, responsibilities, equipment operated, etc. for position(s) held: Describe your reason(s) for leaving: Employer's Name: Street Address: Supervisor's Name: Dates Employed: Job Title, Beginning and Ending: Salary, Beginning and Ending: Describe your duties, responsibilities, equipment operated, etc. for position(s) held: Describe your reason(s) for leaving: Employer's Name: Street Address: Supervisor's Name: Dates Employed: Job Title, Beginning and Ending: Salary, Beginning and Ending: Describe your duties, responsibilities, equipment operated, etc. for position(s) held: Describe your reason(s) for leaving: Employer's Name: Street Address: Supervisor's Name: Dates Employed: Job Title, Beginning and Ending: Salary, Beginning and Ending: Describe your duties, responsibilities, equipment operated, etc. for position(s) held: Describe your reason(s) for leaving: Section IV - Educational Experience and Training Please select the last year of formal education you have completed: 1 2 3 4 5 6 7 8 9 10 11 12 Name of school: Address: College: 1 2 3 4 5 6 7 Technical School: 1 2 3 4 Other (please explain): If a graduate, please state degree(s): Please describe the courses you took or technical training you have received from school which you feel would help you perform the job for which you are applying: (include special machines or equipment you operate, hobbies, or volunteer work projects which have taught you qualifying skills, etc.) Section V - Miscellaneous Do you have any commitments which might interfere with or adversely affect your employment with the County? (Exclude commitments which might indicate race, age, color, religion, sex, national origin, or physical handicap) Yes No If yes, please explain: Do you presently have or are you willing to obtain a valid State of Ohio Certified Driver's License (CDL)? (This information will be considered for selection purposes if such licensure is required by law to perform the duties of the position for which you are considered.) Yes No Have you filled an application here before? Yes No Have you ever been employed here before? Yes No Give name, address and phone number of three references not related to you: Name Address Phone Have you ever been convicted of or pleaded guilty to a criminal offense? Yes No If yes, please explain: I solemnly swear that all of the information furnished in this Employment Application is true, accurate and complete to the best of my knowledge. I understand that any misrepresentation or falsification of the information provided may lead to withdrawal of an employment offer or termination following employment. Name Date