GRANT COUNTY MOSQUITO CONTROL DISTRICT #1
Application for Employment
The Grant County Mosquito Control District #1 complies with all federal and Washington State rules and regulations and does not discriminate on the basis of race, creed, color, national origin, gender, sexual orientation, marital status, age or disability.
Personal Information
Date ______
Last Name ______First Name ______Middle Int.______
Street Address ______
City ______State ______Zip ______Home phone: ( )______
Mobile phone ( )______Social Security Number______
Position applied for ______
How did you hear of this opening? ______
When can you start? ______Desired Wage $ ______
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You may be required to provide documentation.) Yes No
Are you looking for full-time employment? Yes No
If no, what hours are you available? ______
Are you willing to work occasional night shift 8pm -12am? Yes No
Have you ever been convicted of a felony? Yes No
If yes, please describe conditions. ______
______
Education
School Name and Location Year Major Degree
High School ______
College ______
College ______
Post College ______
Other Training ______
In addition to your work history, are there other skill, qualifications, or experience that we should consider? ______
______
Employment History (Start with most recent employer)
Company Name ______
Address ______Telephone ______
Date Started ______Starting Wage ______Starting Position ______
Date Ended ______Ending Wage ______Ending Position ______
Name of Supervisor ______
May we contact? Yes No
Responsibilities ______
______
Reason for leaving ______
Company Name ______
Address ______Telephone ______
Date Started ______Starting Wage ______Starting Position ______
Date Ended ______Ending Wage ______Ending Position ______
Name of Supervisor ______
May we contact? Yes No
Responsibilities ______
______
Reason for leaving ______
Company Name ______
Address ______Telephone ______
Date Started ______Starting Wage ______Starting Position ______
Date Ended ______Ending Wage ______Ending Position ______
Name of Supervisor ______
May we contact? Yes No
Responsibilities ______
______
Reason for leaving ______
Additional Information (Examples include classes, certificates, current licenses, specific equipment and other skills that could help qualify you for this position.)
______
References (Preferably persons who know about your work/training.)
Name Address Phone Number
______( ) ____-______
______( ) ____-______
______( ) ____-______
Attach additional information if necessary.
I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigations of my prior educational and employment history.
I understand that employment at this company is “at will,” which means that either I or this company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis.
Signature: ______Date: ______
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