Please print out and send this form to

Please print out and send this form to: The Holmes County Commissioners Office; 2 Court Street, Suite 14; Millersburg, Ohio 44654. FAX: (330) 674-0566

Holmes County

Application for Employment

An Equal Opportunity Employer

Agency __________________________________________________________

Applicants for employment with the County are evaluated and selected on the basis of individual merit and ability with respect to the position being filled. Applicants are selected and hired without discrimination based on race, color, religion, sex, age, national origin, political affiliation, disability or ancestry.

Applicants may request reasonable accommodation in the application/interview process.

PLEASE PRINT

Name (last, first, middle):_____________________________________________________________________

Address: __________________________________________________________________________________

___________________________________________________________________________________________

Telephone: ______________________________ Social Security Number:____________________________

Application Date: ______________ Veteran? Yes No Branch of Service _____________________

ARE YOU LEGALLY PERMITTED TO WORK IN THE UNITED STATES? Yes No

PERSONAL DATA

Position(s) Desired: _____________________________________________ Full-Time Part-Time

Date available to Start? __________________________________________________________________

Have you previously applied for a job with the County? Yes No When? __________________

Have you ever been employed by the County? Yes No Dates: __________________________

Reason for leaving? ______________________________________________________________________

Are you related to anyone employed by the county? Yes No

State Name and Relationship: _______________________________________________________________

Answer the following three questions only if driving is an essential function of the job for which you are applying:

Do you have a valid Ohio driver's license? Yes No

Do you presently have or are you willing to obtain a valid Ohio commercial driver's license? Yes No

Has your driver's license been suspended or revoked within the last 3 years? Yes No

Do you have any time commitments that might interfere with your employment?

If yes, please explain _______________________________________________________________________

_________________________________________________________________________________________

Have you ever been employed by another public employer in Ohio? Yes No

If Yes, provide place and dates of service: ______________________________________________________

Are you able to perform the essential functions of the job(s) for which you are applying with or without reasonable accommodation? (please refer to job description) Yes No

If No, please explain:_______________________________________________________________________

________________________________________________________________________________________

Have you ever been dismissed from or asked to resign from any employment position? Yes No

If Yes, please explain: _____________________________________________________________________

________________________________________________________________________________________

EDUCATIONAL DATA

Name of School or College	Location: City, State, Zip	Major Subject/Degree	Scholastic Average	Did you graduate?
High School:
College/University:
Other Schools Attended:
Other (Specify):

EMPLOYMENT DATA

List all previous employment for the last ten years in chronological order- last position first- including U.S. Military. Attach additional pages if needed or resume if desired.

Employer		Telephone
Address		Final Salary
Dates Employed FROM: TO:	Position(s) Held:	Supervisor:

Employer		Telephone
Address		Final Salary
Dates Employed FROM: TO:	Position(s) Held:	Supervisor:

Employer		Telephone
Address		Final Salary
Dates Employed FROM: TO:	Position(s) Held:	Supervisor:

If employed, why do you wish to leave your present employer?

__________________________________________________________________________________________

May we contact your present employer for a reverence? Yes No

Describe briefly the type of work which you are best qualified to do by reason of background, education, previous employment or training, and tell why you feel qualified for the position(s) for which you are applying:

__________________________________________________________________________________________

List professional organization memberships and offices held, excluding those which would indicate race, color, religion, sex, age, national origin, political affiliation, disability and/or ancestry:

__________________________________________________________________________________________

PERSONAL REFERENCES OTHER THAN FORMER EMPLOYERS AND RELATIVES

Name	Address and Telephone	Occupation
1.
2.
3.

CERTIFICATION

I certify that all information contained in this application is true, complete and correct to the best of my knowledge. I understand that any material omission, misrepresentation or falsification of this information is grounds for dismissal from or refusal of employment. I hereby authorize investigation of all statements contained in this application and give permission to contact all or any of my previous employers, references and/or schools for information. I also give my consent to contact the State Motor Vehicle Department for a Moving Vehicle Violation Report if such information is required to perform the duties of the position. I indemnify and hold harmless all persons either providing or receiving information, verbal or written, pursuant to this application.

Applicant's Signature: ____________________________ Date: ___________________

HOLMES COUNTY- DRIVING ELIGIBILITY APPLICATION

TO BE INCLUDED IN THE APPLICATION FOR ALL PROSPECTIVE NEW EMPLOYEES ESPECIALLY THOSE WHO MAY ON OCCASION DRIVE A COUNTY VEHICLE OR ANY OTHER VEHICLE ON BEHALF OD THE COUNTY.

(PLEASE PRINT)

FIRST, MIDDLE & LAST NAME: ____________________________________________________________________________

ADDRESS: ___________________________________________________________________________________________

OHIO DRIVER LICENSE NUMBER: __________________________________________________________________________

SOCIAL SECURITY NUMBER: _____________________________________________________________________________

DATE OF BIRTH: _______________________________________________________________________________________

(THE ABOVE INFORMATION IS REQUIRED BY THE STATE OF OHIO TO RUN A MVR)

POSITION APPLIED FOR: _________________________________________________________________________________

I UNDERSTAND THAT AS A CONDITION OF MY EMPLOYMENT I MUST HAVE A CURRENT AND VALID OHIO DRIVER'S LICENSE AND AN ACCEPTABLE DRIVING RECORD WHICH MEETS THE STANDARDS OF THE COUNTY'S AUTO LIABILITY INSURER. I UNDERSTAND THAT I MUST PAY FOR THE COUNTY TO OBTAIN A COPY OF MY DRIVER'S ABSTRACT REPORT.

I FURTHER UNDERSTAND THAT I MUST PROVIDE, WITH MY APPLICATION, PROOF OF PERSONAL AUTO LIABILITY INSURANCE THAT MEETS THE REQUIREMENT OF THE STATE OF OHIO AND EXISTING COUNTY MINIMUM REQUIREMENTS.

QUESTIONNAIRE:

DURING THE PREVIOUS THREE (3) YEARS HAVE YOU BEEN INVOLVED IN ANY OF THE FOLLOWING:

1.) HAD AUTOMOBILE INSURANCE REJECTED, CANCELLED, REFUSED OR BEEN IN A HIGH RISK INSURANCE PROGRAM?

_______________________________________________________________________________________________________

2.) BEEN INVOLVED IN ANY ACCIDENT EITHER AT FAULT OR NOT AT FAULT? _______________________________________

_______________________________________________________________________________________________________

3.) BEEN ARRESTED FOR ANY TRAFFIC RELATED INCIDENTS? ____________________________________________________

_______________________________________________________________________________________________________

4.) HAD ANY TRAFFIC VIOLATIONS OTHER THAN PARKING? _____________________________________________________

_______________________________________________________________________________________________________

PLEASE PROVIDE ALL DETAILS INCLUDING DATE AND LOCATION FOR ANY QUESTIONS THAT WAS ANSWERED BY "YES".

I UNDERSTAND THAT BY GIVING INCORRECT INFORMATION OR BY OMITTING INFORMATION I AM FALSIFYING MY APPLICATION AND THEREFORE SUBJECT SUBJECT TO DISMISSAL IF HIRED. I FURTHER AGREE THAT THE COUNTY AS MY EMPLOYER MAY CHECK MY DRIVING RECORD AT ANY TIME. I FURTHER AGREE TO REPORT TO MY SUPERVISOR ANY ACCIDENTS, ARREST, SUSPENSIONS, OR CANCELLATION OF PERSONAL INSURANCE AS SOON AS POSSIBLE AFTER THEY OCCUR AND PRIOR TO DRIVING ANY VEHICLE ON BEHALF OF THE COUNTY.

PRIOR TO DRIVING ON BEHALF OF THE COUNTY: I AM AWARE THAT AN ACCEPTABLE DRIVING RECORD IS REQUIRED.

EMPLOYEE: _________________________________ EM: ____________________________ DATE: ____________________

HOLMES COUNTY EQUAL EMPLOYMENT OPPORTUNITY FORM

The Ohio Fair Employment Practice Law prohibits employment practices that discriminate based on race, color, religion, sex, national origin, disability, age or ancestry. The 1964 Civil Rights Act, Title VII, prohibits discrimination based on race, color, religion, sex or national origin.

The Ohio Administrative Code, Section 4112-5-04, requires the Board of Holmes County Commissioners to record and report the information listed below. Please help us comply by providing the answers to the following questions.

This Equal Employment Opportunity form will be kept in a CONFIDENTIAL FILE separate from the Application for Employment. It will not be used to determine employment eligibility.

POSITION APPLIED FOR: ________________________________________________________________________________

RACE/ETHNIC GROUP: American Indian/ Alaskan Native

Asian/ Pacific Islander

Hispanic

Black

White

Other

SEX: Female

Male

VIETNAM ERA VETERAN: Yes

DISABLED VETERAN: Yes

DO YOU HAVE A DISABILITY OR MEDICAL CONDITION THAT NEEDS TO BE ACCOMMODATED TO PROVIDE YOU WITH AN ACCESSIBLE WORK ENVIRONMENT?

Yes

Referred by: Job Posting Newspaper: __________________________________

Friend Other (please specify): _________________________

Thank you for filling out this form.

THIS INFORMATION IS TO BE UTILIZED FOR AFFIRMATIVE ACTION USE ONLY

HOLMES COUNTY POST-OFFER BACKGROUND CHECK RELEASE

I, THE UNDERSIGNED, HEREBY UNDERSTAND THAT ANY OFFER OF EMPLOYMENT MADE BY HOLMES COUNTY WILL BE CONTINGENT UPON THE FOLLOWING:

	POST OFFER DRUG SCREEN
	CRIMINAL BACKGROUND CHECK
	REQUEST FOR A COPY OF MY DRIVER'S ABSTRACT REPORT

I HEREBY RELEASE THE COUNTY TO ACQUIRE THE ABOVE INFORMATION FOR DETERMINING MY ELIGIBILITY FOR EMPLOYMENT.

___________________________/_____________

EMPLOYEE SIGNATURE DATE

PLEASE READ THE FOLLOWING BEFORE COMPLETING OUR APPLICATION BLANK

1.) There is no guarantee of a job offer or job interview in completing out application blank. Your application blank will be considered with others who have submitted applications and decisions about interviews will be based on this comparison.

2.) Our application blank must be completely filled out in order for it to be considered for employment.

3.) If the information provided on our application can not be satisfactorily verified by employment reference checks your application could be considered as incomplete.

4.) Applications are filed according to job title. Be as specific as possible in starting the job applying for: ANY position is not an acceptable response on our application blank.

5.) Due to the large number of applications we receive and the competitive nature of our employment process specific reasons for employment decisions will not be released.

6.) In completing our application blank you will be subject to the following checks:

	EMPLOYMENT REFERENCE CHECK FROM FORMER EMPLOYERS
	CRIMINAL RECORD CHECK
	DRUG SCREEN

______________________________________________________, I have read the above statements.

Signature of Applicant