Telephone No.

Name

Email

Street Address

City, State and Zip

Position for which you are applying:

What type of Employment are you seeking?

Full-time  Part-time

Has Franklin County ever employed you?

Yes  No

If yes, please give the dates of employment, position(s) held, and state your name while employed if different from above:

Name and Address

Course Work

Degree

High School

College (Undergraduate)

College (Graduate)

Other

Work History:  List your most recent employer first.

May we contact your present employer?

Yes No Not Applicable

Most Recent Employer

Street Address

City, State and Zip

Telephone No.

Start Date

/ / (mm/dd/yyyy)

Starting Position

Date Left

/ / (mm/dd/yyyy)

Final/Current Salary

Final/Current Position

Name of Immediate Supervisor

Title of Immediate Supervisor

Description of Duties

Reason for Leaving

Previous Employer

Street Address

City, State and Zip

Telephone No.

Start Date

/ / (mm/dd/yyyy)

Starting Position

Date Left

/ / (mm/dd/yyyy)

Final Salary

Final Position

Name of Immediate Supervisor

Title of Immediate Supervisor

Description of Duties

Reason for Leaving

Previous Employer

Street Address

City, State and Zip

Telephone No.

Start Date

/ / (mm/dd/yyyy)

Starting Position

Date Left

/ / (mm/dd/yyyy)

Final Salary

Final Position

Name of Immediate Supervisor

Title of Immediate Supervisor

Description of Duties

Reason for Leaving

Miscellaneous:

Are you a registered voter in Franklin County?

Yes  No

Are you a U.S. Citizen or otherwise authorized to work in the U.S. on an unrestricted basis?

Yes  No

Did a particular person refer you to this office?

Yes  No

If yes, by whom? 

Do you have any relatives working for city, county, or state government?

Yes  No

If yes, state name and place of employment:

Are there any hours you can not work?

Do you have a physical or medical condition, which would limit your ability to perform usual office tasks, such as lifting boxes, using computer display terminals, cashier equipment, or sitting or standing for extended periods of time?  (This list is not inclusive of requirements.)

Yes  No

If yes, what can be done to accommodate your limitation?

If there is any other task you are unable or limited to perform, please state:

Are you taking any medications, which could impair your ability?

Yes  No

If yes, please explain:

Our usual office attendance policy is 40 hours per week for full-time employment.  Can you meet this requirement?

Yes  No

If hired, how soon could you begin work?

If a position were offered to you, would you submit to pass a drug test administered by a professional?

Yes  No

Have you been convicted of a Felony?
Note: A yes answer does not automatically disqualify you from employment since the nature of the offense, date and type of job for which you are applying will be considered.

Yes  No

If yes, please explain fully:

References will be checked, as well as public records for criminal activity.  Do you have any objections?

Yes  No

If yes, please explain:

References:

List three (3) professional or character references that this office has permission to contact for Professional Recommendation.  Please do not list any relatives or duplicate supervisors whom you may have listed elsewhere on this application.

Name

Phone Number

Type of Reference

-------------------- Professional Personal

-------------------- Professional Personal

-------------------- Professional Personal

I hereby attest that the above information is true and accurate to the best of my knowledge.  If I have provided false or inaccurate information, I acknowledge that I will be subject to discharge.