Otsego County Employment Application Form

Provide information below for all High Schools, Colleges, Universities, Trade or other schools you attend. Do not omit any institutions.

Education

(may or may not be considered depending on the job applied for.)

High School

Name of School*

Address*

Grade completed or degree*

Subjects studied or major*

College

Name of School

Address

Grade completed or degree

Subjects studied or major

Graduate

Name of School

Address

Grade completed or degree

Subjects studied or major

Employment History

(You must complete your work history for all full-time and part-time employment beginning with your most recent employer.)

Company Name*

Address*

Phone number*

Name of Supervisor*

Dates employed From*

Dates employed*

From	To

Pay Rates*

Starting	Ending

State job titles and describe duties*

Reason for leaving*

Type of business*

May we contact this employer?*

Yes
No

Company Name

Address

Phone Number

Name of Supervisor

Dates employed

From	To

Pay Rates

Starting	Ending

State job titles and describe duties

Reason for leaving

Type of business

May we contact this employer?

Yes
No

Company Name

Address

Phone number

Name of Supervisor

Dates employed

From	To

Pay Rates

Starting	Ending

State job titles and describe duties

Reason for leaving

May we contact this employer?

Yes
No

Company Name

Address

Phone number

Name of Supervisor

Dates employed

From	To

Pay Rates

Starting	Ending

State job titles and describe duties

Reason for leaving

Type of business

May we contact this employer?

Yes
No

Explain any gaps in your employment history

Have you ever been forced to resign?*

Yes
No

If yes, please explain*

Did you receive any discipline in the last 12 months of active employment?*

Yes
No

If yes, please explain*

Were you given a performance evaluation within the last 12 months of active employment?

Yes
No

If yes, what was the range of scores used

What was your score?

Military

(Complete only if you served in the military.)

Branch and rank at discharge

Dates of service

From	To

Describe any military skills, training or experiences you believe are relevant to the job applied for

DRIVING RECORD

(May or may not be considered depending on the job applied for.)

Do you have a valid Michigan drivers license?*

Yes
No

Commercial drivers license?

Yes
No

Endorsements

Have you had any tickets?*

Yes
No

If yes, please explain*

Has your drivers license ever been suspended or revoked?

Yes
No

If yes, please explain*

Do you have any DUI or DWI (driving while drunk) convictions?*

Yes
No

If yes, please explain*

References

1. Professional Past Employer

Company Name

Address

Street Address City State ZIP Code

Phone

2. Professional Past Employer

Company Name

Address

Street Address City State ZIP Code

Phone

3. Professional Past Employer

Company Name

Address

Street Address City State ZIP Code

Phone

Resume File

Thank you for your interest in employment with Otsego County.

In order to provide high quality services to Otsego County residents, the County strives to hire the person best qualified for each position.

Resumes and other documentation you wish to submit may be added, but resumes will not be accepted in lieu of a fully completed County application form. We expect that you will take the time to complete all areas of the application form and sign it. The information you provide will be verified. If there are omissions, falsifications or misrepresentations, we will have to withdraw your application from consideration. Should you start employment prior to the completion of the entire verification process, any falsifications or misrepresentations on the application will result in termination of your employment.

Your application is a public record and can be viewed and/or copied upon request from any person.*
*Pursuant to Freedom of Information Act 442 of 1976

Offers of employment are contingent upon the selected applicant passing any testing deemed necessary.

Persons being hired by Otsego County will be checked for the following:

·Driver’s License verification
·Local, state and national criminal history record verification
·Verification of information on the application
·Background investigation with previous employers and others who can attest to your work habits, qualifications and character.
·Post-offer Physical Examination and Drug Screen
·Post-offer Psychological Examination
If you have any questions, you may contact the Human Resources Office, Monday through Friday, from 8:00 a.m. to 4:30 p.m.

ACKNOWLEDGMENT

I authorize Otsego County and its agents to consult with and receive information from other companies, individuals, schools or agencies (public or private) concerning my employment, education, background, criminal or motor vehicle record, competence, experience, character or qualifications, and I authorize them to release such information to Otsego County as the County requests, including without limitation, my prior disciplinary record, without any obligation to give me written notice of such inquiry and/or disclosure. I also authorize Otsego County to release any information concerning my employment to any prospective or subsequent employers without any obligation to give me written notice of such disclosure. I authorize the Social Security Administration to verify that the Social Security number I will furnish is my assigned number and is valid for employment purposes. I hold harmless and release Otsego County and any individual, institution, company or agency from any liability as a result of the above inquiries and disclosures.

I understand that this Application is not an offer or a contract of employment. If I am hired by Otsego County, I will be bound by the rules, policies, regulations, terms and conditions of employment of Otsego County as they may be communicated to me from time to time by the County and which may be changed or modified at the will of the County, in its sole discretion, with or without cause, or notice to me. I further understand and agree that Otsego County is an at-will employer which means that my employment relationship with Otsego County is for no definite period and subject to the express terms of any collective bargaining agreement covering my employment, may be terminated at any time, with or without cause, with or without notice, at the will of either Otsego County or me. I understand that the direction and control of all work is the sole prerogative of Otsego County and includes, by way of illustration only, the right to hire, layoff, transfer, reassign, demote or discharge. Only the Otsego County Board of Commissioners has the authority to enter into any agreement for employment for any specific period of time.

I understand that according to federal law, I must produce documentation to verify my identity and authorization to work in the U.S. I agree that any employment with Otsego County is contingent on my ability to obtain and maintain the required documentation within the time period required by applicable law.

I certify that all of the information in this Application (and other information given by me in support of my application) is true and complete. I understand that any misrepresentation, misleading statement or omission of any fact by me in this Application, in support of my application for employment, or during my employment, is sufficient reason for my (1) not being offered employment or (2) being disciplined, up to and including discharge, at any time during my employment in the sole discretion of Otsego County.

I understand and agree that as a condition of employment, I may be required to undergo a post-offer medical examination, which includes a drug test. During any employment with the County, I understand that I may be required to submit to an alcohol or drug screening at the request of the County and I authorize the release of any such tests results to appropriate personnel of the Company. I further agree that during any employment with the County if I need an accommodation as the result of a disability, I will promptly notify the appropriate Otsego County representative of my need for accommodation in writing within 182 days after I learn of the need.

I acknowledge that this application will remain active for six (6) months from this date. If I have not heard from the County at the conclusion of this six (6) month period, it is my responsibility to complete a new application if I still wish to be considered for employment by the County.

I agree that any claim or lawsuit relating to my application for employment, or service with Otsego County must be filed no more than six (6) months after the date of the employment action(s) or event(s) that is the subject of my claim or lawsuit. I voluntarily and knowingly waive any statute of limitations to the contrary.

Terms*

I have read and understand the terms of this application.

Comments

This field is for validation purposes and should be left unchanged.

Employment Application

Step 1 of 2

Personal Information

Education

High School

College

Graduate

Employment History

Military

DRIVING RECORD

References

1. Professional Past Employer

2. Professional Past Employer

3. Professional Past Employer