Franklin County Veterans Service Commission

EMPLOYMENT APPLICATION

FRANKLIN COUNTY VETERANS SERVICE COMMISSION

GENERAL INFORMATION

*Last Name: *First Name: Middle Initial:

*Street Address:

*City: *State: *Zip Code:

*Phone: Area Code: Number:

Alternate Phone: Area Code: Number:

Are you interested in:
Full time permanent work? Yes No
Part time permanent work? Yes No
Temporary work? Yes No
Summer work? Yes No
Position for which you are applying:
*Have you ever been employed by Franklin County? Yes No
If yes, please give dates of employment, position(s) held, and state your name while employed if different from above:

*EDUCATION

	NAME AND ADDRESS OF SCHOOL	COURSE WORK	DEGREE
HIGH SCHOOL
COLLEGE (UNDERGRADUATE)
COLLEGE (GRADUATE)
OTHER

TRAINING AND OTHER QUALIFICATIONS

If applying for a clerical position: Typing Speed: Shorthand Speed:
If you have received training in an area which you feel is relevant to the position(s) for which you are applying, please submit the following information (do not include training gained as a part of your education as previously described).

	Type of Training	Organization	Length of Training	Subject(s) Covered
1)
2)
3)

*EXPERIENCE

In the areas below, please list past work experience beginning with the most recent employment. If the title and duties changed in the course of your service in any one organization, indicate such changes clearly and as separate employments. Volunteer work may also be included as employment.

1)
*Employer's name and address:

*Length of Employment: *From Date: *To Date:
*Reason for Leaving:
*Position (job title and classification):
*Salary: Beginning: Ending:
*Duties Performed:

2)
Employer's name and address:

Length of Employment: From Date: To Date:
Reason for Leaving:
Position (job title and classification):
Salary: Beginning: Ending:
Duties Performed:

3)
Employer's name and address:

Length of Employment: From Date: To Date:
Reason for Leaving:
Position (job title and classification):
Salary: Beginning: Ending:
Duties Performed:

4)
Employer's name and address:

Length of Employment: From Date: To Date:
Reason for Leaving:
Position (job title and classification):
Salary: Beginning: Ending:
Duties Performed:

MISCELLANEOUS
If hired, will you be able to work during the normal days and hours required for the position(s) for which you are applying?
Yes No If no, please explain:

Do you have any commitments to another employer that might affect your employment with the county?
Yes No If yes, please explain:

If hired, can you furnish proof that you are eligible to work in the United States?
Yes No

Do you understand the duties of the position for which you are applying?
Yes No

Are you able to perform the essential functions of the position for which you are applying?
Yes No If no, please explain:

*Have you been convicted of a felony?
Yes No
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. If yes, please explain fully:

*REFERENCES

Please list the names and addresses of three individuals, other than relatives, whom we may contact for a professional recommendation. (e.g., past or present employers, supervisors, etc.)

NAME	ADDRESS	CITY	STATE	ZIP CODE	PHONE

EMERGENCY INFORMATION

NAME	ADDRESS	CITY	STATE	ZIP CODE	PHONE

We will request that applicants sign their application and provide their social security number at the time of their interview.

I certify that, to the best of my knowledge and belief, all of my statements are true, correct, and complete. If I have provided false or inaccurate information, I acknowledge that I will be subject to discharge.

I consent to a release of information by present or former employers, schools, law enforcement agencies, and other individuals and organizations, as needed by the Veterans Service Board of Commissioners to lawfully assess my ability to perform the job for which I am applying.