Application for Employment s35

Dawes County 451 Main Street Dawes County Chadron, NE 69337 Application for Employment 308-432-0102

Name: Phone Number(s): *Please include area code Mailing Address (Street, City, State, Zip Code): E-mail Address:

Are you legally entitled to work in the U.S.? Do you have a valid Driver’s License? Yes No Yes No State issued by: Have you ever been employed by Dawes County or any Are you related to anyone in the employ of Dawes affiliated Dawes County Office? Yes No County? Yes No When: Who: Position/Job Title: Relationship: Would you like to request Veterans Preference? Yes* No *If yes, please attach a copy of your DD-214 discharge papers. If also requesting disability credit or preference as a spouse of a disabled veteran, please attach the appropriate documentation per Nebraska Revised Statute 23-2529. Do you meet the state minimum age requirement to work? Are you over 18? Yes No If no, are you at least 16 years of age? Yes No

Type of Position Desired Full-Time Part-Time Temporary Date Available: Position applying for: Salary Expected: $

General Information List five references other than relatives who have knowledge of your skills and character.

Name Phone Number How do you know this reference?

List other special skills and professional or occupational licenses:______1 of 3 Employment Record List your most recent job first. All items must be completed even if included on your resume.

Company (current): Address: City, State, Zip: Phone: Job Title: Immediate Supervisor: Primary Duties:

Reason for Leaving: Employed From: To: Salary: Starting $ Ending $ May we contact your current employer? Yes No

Company: Address: City, State, Zip: Phone: Job Title: Immediate Supervisor: Primary Duties:

Reason for Leaving: Employed From: To: Salary: Starting $ Ending $

Company: Address: City, State, Zip: Phone: Job Title: Immediate Supervisor: Primary Duties:

Reason for Leaving: Employed From: To: Salary: Starting $ Ending $ Educational Background Name/Location of School Grade/Credit Major Subjects Degree, Certification, or Hour Completed Studied Diploma Received 1. 2. 3. 4. Please read the following carefully before signing this application: I attest to the accuracy and truthfulness of the information provided, and I understand that falsification or omission of any information on this application could result in my disqualification from further consideration in the selection process, or, if hired, termination of my employment A facsimile copy or electronic version of this document shall be considered as effective and valid as the original. Additionally, upon my termination I authorize the release of reference information on my work.

______Applicant Signature* Date 2 of 3

Dawes County is an Equal Opportunity Employer. To request reasonable accommodation, contact Dawes County Human Resources at (308) 432-0102 or via email at [email protected] REV 05/14 Attachment I Dawes County Employment Application

Consent for Disclosure of Current or Former Employment Information

I hereby give consent to any and all previous employers and references of mine to provide information to Dawes County with regard to my employment with prior employers.

Dawes County may or may not contact my current employer prior to hiring.

This authorization will expire six months from the date it is signed.

______Applicant Signature Date

3 of 3

Dawes County is an Equal Opportunity Employer. To request reasonable accommodation, contact Dawes County Human Resources at (308) 432-0102 or via email at [email protected] REV 05/14