County of Greene, Missouri Employment Application Human Resources Department 933 North Robberson Springfield, MO 65802 (417)868-4116 TDD: (417)862-6725 Jobs Hotline: (417)868-4117 Fax: (417)868-4818 Please inform us if you require assistance in filling out an application or taking a preemployment test. Individuals with disabilities should request reasonable accommodations in accordance with the Americans with Disabilities Act prior to testing or appointment. APPLICATION FOR EMPLOYMENT Instructions to Applicant: Please TYPE OR PRINT legibly and complete all pages of this application. Please sign the last page. Resumes and other materials may be attached. Position Desired: Date Available: Employment Desired: Full-time Part-time Temp Days/Hours Available for Work: PERSONAL INFORMATION SOCIAL SECURITY NUMBER NAME (Last, First, Middle) ADDRESS (Street - City - County - State - Zip Code) TELEPHONE (Home) TELEPHONE (Message) Are you over 18 years of age? Yes No Are you legally permitted to work in the United States? Yes No Do you have any relative(s) that work for Greene County? If YES, list name(s), relationships, and department: Yes No Have you ever been convicted as an adult of any law violation? If YES, list complete conviction record - use additional sheets, if necessary. Please give full details, including dates, type of offense, location, etc.: Yes No (Proof of U.S. Citizenship or immigration status will be required upon employment) Greene County is an Equal Employment Opportunity Employer American LegalNet, Inc. www.FormsWorkflow.com EMPLOYMENT EXPERIENCE In the space below, list your complete record of employment for the past TEN years and any other relevant work/volunteer experience. Start with your present or most recent position and list each position in the order that you held them. List any periods of unemployment of one month or more. If the vacancy announcement includes an experience requirement, be sure to show clearly that you meet such requirement. If more space is needed, attach separate sheet(s) to this application. Employer Dates of Employment Start Date May we contact employer? If no, explain: End Date Yes No Starting Salary Final Salary Address Phone Number Reason for Leaving Your Job Title Supervisor’s Name and Title Description of Duties Dates of Employment Employer Start Date May we contact employer? If no, explain: End Date Yes No Starting Salary Final Salary Address Phone Number Reason for Leaving Your Job Title Supervisor’s Name and Title Description of Duties Dates of Employment Employer Start Date May we contact employer? If no, explain: Yes No Starting Salary End Date Final Salary Address Phone Number Reason for Leaving Your Job Title Supervisor’s Name and Title Description of Duties American LegalNet, Inc. www.FormsWorkflow.com EDUCATION AND TRAINING Please complete all appropriate items. To receive credit for college education, you must submit a copy of your transcript(s). Type of School Name and Location of School Type Degree Received and/or Credit Hours Earned Major/Minor Fields of Study Did you graduate or obtain equivalency diploma (GED)? Yes No High School Vocational Education College or University Graduate School Other Training (Explain) PROFESSIONAL INFORMATION (if applicable) Please list any professional, paraprofessional, or technical certificates or licenses that you currently hold (include peace officer certification, motor vehicle operator license, CDL etc., if it is a requirement of the position for which you have applied). License or Certification Held: Licensing State and/or Agency: LAW ENFORCEMENT APPLICANTS ONLY Are you an United States citizen? Yes No Please attach the following information which is a requirement for Missouri POST Certification: $ Proof of U. S. Citizenship. $ Missouri Peace Officer Certification. List below any information concerning military duty, if any: Branch of Service: Type of Discharge: Dates of Service: ADDITIONAL QUALIFICATIONS Please list any other knowledge, special technical or computer skills, and/or individual capabilities not previously listed that would especially prepare you for the position for which you have applied? _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com PERSONAL REFERENCES Please list the names of three persons, who are not related to you and not previously listed as a current or former supervisor, that we may contact for a personal reference. Name Telephone ( ) - ( ) - ( ) Years Known - CERTIFICATION OF APPLICANT AND AUTHORIZATION FOR RELEASE OF INFORMATION Please read the statements below carefully. Your signature indicates that you fully understand and agree to the provisions of each statement. Name: Social Security Number: I certify that all statements made by me on this application are true and complete to the best of my knowledge. I understand that any false or inaccurate information could result in disqualification of this application and/or termination of employment if I have been employed. I understand and agree that employment with Greene County is voluntarily entered into, and employees are free to resign at will at any time, for any reason, with or without cause or notice. I further understand and agree that the county or any elected official thereof, may terminate the employment relationship at will at any time, for any reason, with or without cause or notice. This is not a contract for employment. It is further understood and agreed that should my employment with Greene County be terminated for any reason, my final pay will not be received until I have submitted all necessary paperwork and returned any and all property assigned to me and during the course of my employment, including but not limited to all keys, uniforms, equipment, and county-issued identification. In consideration of my employment, I agree to conform to the policies, procedures, and regulations of Greene County. I, the undersigned, do hereby authorize Greene County to conduct an investigation in respect to my application and release the county, my former employers, and personal references from any liability for damage caused by giving and receiving information or opinions as to my employment or character. Any information obtained through former employers and/or personal references will become the property of Greene County. I, the undersigned, do hereby authorize the release of any information which pertains to records of convictions for law violations, including felony, misdemeanor and traffic violations, and agree to hold Greene County harmless and in no event shall the county be liable to me for special, indirect or consequential damages for the refusal of employment due to information obtained during my police record check. I further understand that any offer of employment is conditioned upon the results of reference checks, and, if a requirement of the position, police record checks, background checks, drug testing, and post-offer physical exams Applicant Signature: Date: _____________ American LegalNet, Inc. www.FormsWorkflow.com