Lawrence County - Employment Application

Position(s) Applied For*

Date of Application*

First Name*

Last Name*

M.I.

Address*

City*

State*

Zip Code*

U.S. phone number*

Alternate Number

Email*

If you are under 18 years of age, can you provide required proof of your eligibility to work, choose Yes or No? Yes No

Choose Yes or No.

Have you ever been convicted of a felony, Yes or No? *Required Yes No

Choose Yes or No. (Conviction will not necessarily disqualify an application from employment)

If yes, explain

Have you ever filed an application with us before, Yes or No? Yes No

Choose Yes or No.

If yes, give date

Do any of your friends or relatives work here, Yes or No? Yes No

Choose Yes or No.

If yes, state name, relationship and location

Are you currently employed, Yes or No? Yes No

If yes, may we contact you present employer and please provide name

Do you have a valid driver's license, Yes or No? *Required Yes No

Education History

Name and Address of School

High School Education

Course of Study

High School Education

Number of Years

High School Education

Diploma or Degree

High School Education

Name and Address of School

College

Course of Study

College

Number of Years

College

Diploma or Degree

College

Name and Address of School

Other

Course of Study

Other

Number of Years

Other

Diploma or Degree

Other

Employment History

Employer 1

Present or last job

Address

Dates of Employement

From - To

Telephone Number

Description of Duties

Starting/Present Job Title

Starting Hourly Rate/Salary

Supervisor

Final Hourly Rate/Salary

Reason for Leaving

May we contact Employer, Yes or No? Yes No

Employer 2

Last Job

Address

Dates of Employment

From - To

Telephone Number

Description of Duties

Starting/Present Job Title

Starting Hourly Rate/Salary

Supervisor

Final Hourly Rate/Salary

Reason for Leaving

May we contact Employer, Yes or No? Yes No

Personal/Professional References

Name

Phone Number

Best Time to Call

Occupation

Name

Phone Number

Best Time to Call

Occupation:

Name

Phone Number

Best Time to Call

Occupation

I hereby authorize the County of Lawrence to thoroughly investigate my references, work records, education, criminal history, and other matters related to my suitability for employment and, further, authorize my current forms employers to disclose to the company any and all letters, reports and other information pertaining ot my employment with the, without giving me prior notices of such disclosure. In addition, I hereby release the County of Lawrence my current and former employers, and all other persons, corporation, partnerships and associations from any and all claims, demands or liabilities arising out of or in any other related to such investigation or disclosure.

By entering your initials electronically, you are signing and agreeing to these statements.

I understand that if offered employment, the offer is contingent on my passing a pre-employment alcohol and drug screen and alcohol/drug screen and pre-employment physical. By signing this application, I voluntarily agree to submit to a pre-employment alcohol/drug screen and pre-employment physical upon receipt of a verbal offer of employment. I understand that failure to pass the alcohol/drug screen and/or physical will result in withdrawal of the employment offer.

By entering your initials electronically, you are signing and agreeing to these statements.

Consent agreement By submitting this form, I acknowledge that this webform is not a secure or private means of communication. I understand that the information I provide may be accessible to personnel outside of the Human Resources (HR) department, and there is no guarantee of confidentiality. If I need to submit sensitive or confidential information, I understand that I will need to contact the HR department directly.

By clicking the consent box and/or submitting this form, I confirm that I accept these terms.

COUNTY OF LAWRENCE

Application for Employment