EMPLOYMENT APPLICATION
JUNEAU COUNTY HUMAN RESOURCES
220 EAST STATE STREET, ROOM 205, MAUSTON, WI 53948
608-847-9327
POSITION APPLIED FOR Click here to enter text.
DATE Click here to enter a date.
Name (Last, First, Middle)Click here to enter text. / Social Security Number
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Current Address (Street, City, State, Zip)
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Telephone Number
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Are you a United States citizen or a permanent resident alien? Choose an item.
If not, what is your immigrant status? Click here to enter text. (If you are hired, you will be required to submit verification of your legal right to work in the United States.)
Have you filed an application with us before? Choose an item. If so, when? Click here to enter text.
Date available to begin employment: Click here to enter a date.
Please check employment preference: Choose an item.
Driver’s License Number: Click here to enter text. Is this license Wisconsin or Out-of-State? Choose an item.
CDL Classifications Click here to enter text. CDL Endorsements Clickthis is a test here to enter text.
Are you at least 18 years of age? Choose an item.
EDUCATION
School / Name and Location of School / Major Field / Highest Grade Completed / Degree or Diploma EarnedHigh School / Click here. / Click here / Click here / Click here /
College / Click here. / Click here. / Click here. / Click here. /
Graduate / Click here. / Click here. / Click here. / Click here. /
Professional license/Registration Click here to enter text.
List any other education, training, specific skills, certificates and licenses that you possess related to this job:
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List any machines or equipments that you are qualified/experienced at operating: Include typing speed.
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EMPLOYMENT HISTORY
Are you currently employed? Choose an item. May we contact your current employer? Choose an item.
List any previous names used in employment history: Click here to enter text.
List your previous employment below, if applicable:
Company NameClick here to enter text. / Telephone
Click here to enter text. / Dates of Employments
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Address
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Supervisor’s Name
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Describe work
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Company Name
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Click here to enter text. / Dates of Employments
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Address
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Supervisor’s Name
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Describe work
Click here to enter text. / Reason for leaving
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Company Name
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Click here to enter text. / Dates of Employments
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Address
Click here to enter text. / Job Title/Position
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Supervisor’s Name
Click here to enter text. / Ending Salary
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Describe work
Click here to enter text. / Reason for leaving
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Company Name
Click here to enter text. / Telephone
Click here to enter text. / Dates of Employments
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Address
Click here to enter text. / Job Title/Position
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Supervisor’s Name
Click here to enter text. / Ending Salary
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Describe work
Click here to enter text. / Reason for leaving
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Company Name
Click here to enter text. / Telephone
Click here to enter text. / Dates of Employments
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Address
Click here to enter text. / Job Title/Position
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Supervisor’s Name
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Describe work
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PERSONAL REFERENCES
(Do not include relatives or previous employers)
NAME / ADDRESS / BUSINESS / TELEPHONE NUMBERClick here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Have you ever been involuntarily terminated from a job? Choose an item. If yes, provide name of employer and a brief explanation of the circumstances. Click here to enter text.
Have you been convicted of a felony or a misdemeanor in the last 10 years? Choose an item.
If yes, when? Click here to enter text.
If yes, for what have you been convicted? Click here to enter text.
Icertifythattheanswersgivenbyme inthisapplication aretrueandcorrectwithoutomissionsofanykind.Iunderstand that any misleading or incorrect statementswill render this application void, and ifemployedwill result in termination. I agree that JuneauCounty shall not be held liable in any respect if my employment is terminated becauseof false statements, answers or omissions madeby me inthis application and through this process.
I also authorize pertinent companies, schools, agencies orpersons to give any information requested regarding my employment, character, experience, qualifications and/or suitability for employment. I hereby forever release,discharge andcovenantnottosueanypersonororganizationfor anyresultofproviding,obtainingoracting uponsuchinformation.I understand that such information is sought with confidentiality andI will not request copies ofsuch information. In addition, a copy of this authorization is as validas the original andshould be recognized as such.
Iunderstandthatanyofferofemploymentorcontinuedemployment,ifhired,maybeconditionaluponpassingaphysical examination,includingsubstance abusescreening. Refusal toparticipatewill result in termination or denialof employment.
Qualifiedapplicantsreceiveequalconsiderationandnoquestion askedisforthepurposeofexcludinganapplicantdueto age, race, religion, creed, color, handicap, marital status, sex, sexual preference,national origin, ancestry, arrest, or conviction record as prohibited by law orregulation. JUNEAU COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER.
Signature of Applicant: Date:
Theapplicationwillremain onfilefor6monthsfromthedateofapplication.Incompleteapplicationswillnotbe processed. Juneau County will not accept the telephone updates of applications.
JUNEAUCOUNTY RELEASE OF INFORMATION
AUTHORIZATION FOR RELEASE OF INFORMATION
(for official use only, not tobe released to unauthorized individuals)
Informationprovidedbymeinsupportofmyapplicationfor employmentistrueandcorrecttothebestofmyknowledge.I understand that misrepresentations or omission(s) may be cause for rejectionsor may be cause forsubsequent dismissal if I am hired.
IauthorizearepresentativeofJuneauCountywithinsixmonthsofthedateonthisapplication,toobtaininformationand records pertaining to me from any or all ofthe followingsources:
1.Municipal, State or Federal law enforcement agencies
2.Selective Service System
3.Any banking Institution
4.Any place of business (purpose ofobtaining credit or employment data)
5.Credit ratingbureaus or institutions maintaining individual credit rating files
6.Any previous employer
7.Present employer (unlessotherwise requested)
8.Personal references as provided on application
9.Any school, college, university or other educational institution
10. Any law enforcement certification or licensing board of Wisconsin orany other state
Exceptions to this blanket authorization
1.Any medical information in the possession of any source named above until subsequent to a conditional offer of employment (per Americans WithDisabilities Act)
2. Click here to enter text.
3. Click here to enter text.
This release is executed toauthorize JuneauCounty, as a prospective employer, to obtain information. It is understood thatsaidinformationshallbeusedonlyinconsiderationof myemploymentandshallnotbefurtherdisseminatedforany purpose.
Applicant SignatureDate
INSERTTOAPPLICATIONFOREMPLOYMENTWITHJUNEAUCOUNTY
Positionapplying: Click here to enter text. Date: Click here to enter a date.
AffirmativeActionInformation
InorderforustomeasuretheprogressofourAffirmativeActionProgramasestablishedbyourCountyBoardof Supervisors,werequestthatyouprovidethefollowinginformation.The StateofWisconsinpermitsustoaskapplicantsto voluntarilydeclaresuchinformationprovideditisusedonlyforstatisticalpurposes.Thissectionwillbedetachedfrom
yourapplicationformandkeptconfidential.
Sex:Choose an item.
Date of Birth: Click here to enter a date.
How do you describe yourself in the following terms: Choose an item.
Veteran Status: Choose an item.
Marital Status: Choose an item.
Handcap: Click here to enter text.
How did you hear about this vacancy? Click here to enter text.