<p> Dawes County 451 Main Street Dawes County Chadron, NE 69337 Application for Employment 308-432-0102</p><p>Name: Phone Number(s): *Please include area code Mailing Address (Street, City, State, Zip Code): E-mail Address:</p><p>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</p><p>Type of Position Desired Full-Time Part-Time Temporary Date Available: Position applying for: Salary Expected: $ </p><p>General Information List five references other than relatives who have knowledge of your skills and character.</p><p>Name Phone Number How do you know this reference?</p><p>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.</p><p>Company (current): Address: City, State, Zip: Phone: Job Title: Immediate Supervisor: Primary Duties: </p><p>Reason for Leaving: Employed From: To: Salary: Starting $ Ending $ May we contact your current employer? Yes No</p><p>Company: Address: City, State, Zip: Phone: Job Title: Immediate Supervisor: Primary Duties: </p><p>Reason for Leaving: Employed From: To: Salary: Starting $ Ending $ </p><p>Company: Address: City, State, Zip: Phone: Job Title: Immediate Supervisor: Primary Duties: </p><p>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.</p><p>______Applicant Signature* Date 2 of 3</p><p>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</p><p>Consent for Disclosure of Current or Former Employment Information</p><p>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. </p><p>Dawes County may or may not contact my current employer prior to hiring. </p><p>This authorization will expire six months from the date it is signed.</p><p>______Applicant Signature Date</p><p>3 of 3</p><p>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</p>