Iowa State University Extension and Outreach – Tama County

EMPLOYMENT APPLICATION

An Equal Opportunity/Affirmative Action Employer

Iowa State University Extension and Outreach-Tama County does not discriminate on the basis of race, color, age, religion, national origin, sexual orientation, sex, marital status, disability or status as a U.S. Vietnam Era Veteran.

NOTE: If you would like a copy of your application for your records, please make a copy before submitting the original to our office.

1. Full Name

Last First Middle

2. Telephone Number(s) / ( ) / - / ( ) / -

Area Code/Primary/Home number Area Code/Alternate number

3. Address

Street/P. O. Box/Apt # City State Zip

4. Are you 18 years of age or older? / (Yes/No)
5. Are you legally authorized to work in the United States? / (Yes/No)

EDUCATIONAL DATA

High School Graduate or Equivalent (GED)? / (Yes/No)
Name and location of high school, college, vocational/technical schools / From / To
(Most Recent First) / Mo / Yr / Mo / Yr / Major or Course Title / Degree
a.
b.
c.
d.

EMPLOYMENT DATA

A. If you had more than one position with the same employer, list each separately.

B. If a job was part time, list the average number of hours worked per week.

C. When describing a job, briefly describe the major tasks performed.

D. Volunteer work experience will be evaluated in the same manner as paid employment and should be entered the same.

- over-

1. EMPLOYMENT HISTORY (Current )

Employer / Type of Business
Employer's Address & Phone #
Your Title / Supervisor's Name
Employed from / / / to / / / Average hours per week employed
month/year / month/year
Reason for leaving
List all machines/equipment/software used on the job:
List number and title(s) of employees supervised:
Duties: (Be Specific)

2. EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address & Phone #
Your Title / Supervisor's Name
Employed from / / / to / / / Average hours per week employed
month/year / month/year
Reason for leaving
List all machines/equipment/software used on the job:
List number and title(s) of employees supervised:
Duties: (Be Specific)

3. EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address & Phone #
Your Title / Supervisor's Name
Employed from / / / to / / / Average hours per week employed
month/year / month/year
Reason for leaving
List all machines/equipment/software used on the job:
List number and title(s) of employees supervised:
Duties: (Be Specific)

- over-

4. EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address & Phone #
Your Title / Supervisor's Name
Employed from / / / to / / / Average hours per week employed
month/year / month/year
Reason for leaving
List all machines/equipment/software used on the job:
List number and title(s) of employees supervised:
Duties: (Be Specific)

Describe background and work experiences that would prepare you for this position:

COMMENTS: To be used to summarize any additional information that you feel may be appropriate.

CERTIFICATION & AUTHORIZATION

I authorize Iowa State University (ISU) Extension and Outreach - Tama County to use the information and statements contained in this application to determine my qualifications for employment. I authorize ISU Extension and Outreach-Tama County to make inquiries of my former employers regarding my previous duties, responsibilities, performance, compensation, and eligibility for rehire. In addition, I authorize ISU Extension and Outreach-Tama County to conduct additional reference checks that may include reference referrals from previous employers.

I understand that a comprehensive background check may be conducted to determine my eligibility for hire. This may include but is not limited to, investigations of criminal and/or conviction records, driving records, and/or a drug screen test as required by U.S. Department of Transportation regulations or university policies.

I certify that all statements made in my application are true and accurate and that I have not omitted any material information or provided false or misleading information. I understand that any material omission or misrepresentation will result in my disqualification from consideration for employment or, if discovered after I begin employment, will result in my termination.

If hired, I agree to abide by the policies of Iowa State University Extension and Outreach-Tama County.

/ / /

Applicant’s Signature Date

Thank you for completing this form.

IOWA STATE UNIVERSITY EXTENSION AND OUTREACH – TAMA COUNTY

IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER