General Information Your Name Your Email Your Telephone Your Street Address Your City Your State Your ZIP Code Positions Applied For Best Time to Call —Please choose an option—MorningsLunch HourAfternoonsEveningsAnytime Employment Information If you’re under 18 and required to do so, can you furnish a work permit? ----YesNoNA If no, why? Have you submitted an application with us before? ----YesNo If yes, dates and positions. Have you been employed with us before? ----YesNo If yes, dates and positions. Are you legally eligible for employment in the United States? ----YesNo Date Available for Work Desired Salary or Hourly Rate Type of Employment Desired ----Full-timePart-timeTemporarySeasonalEducational/Intern Will you travel if required? ----YesNo Will you work overtime if required? ----YesNo These questions are not designed to elicit information about an applicant’s disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. Are you able to meet the attendance requirements of the position? ----YesNo Are you able to perform the essential functions of the job for which you are applying? ----YesNo Have you ever been fired or asked to resign from a job? ----YesNo If yes, dates and positions. Employment History Please include employment for the past 10 years. Most Recent Position Employer Dates of Employment Employer Street Address City State ZIP Code Title of Most Recent Position Held Immediate Supervisor May we contact? ----YesNoLater Reason for Leaving Summary of Job Duties Next Most Recent Position Employer Dates of Employment Employer Street Address City State ZIP Code Title of Most Recent Position Held Immediate Supervisor May we contact? ----YesNoLater Reason for Leaving Summary of Job Duties Next Most Recent Position Employer Dates of Employment Employer Street Address City State ZIP Code Title of Most Recent Position Held Immediate Supervisor May we contact? ----YesNoLater Reason for Leaving Summary of Job Duties Skills and Qualifications Please summarize any special training, skills, licenses, and/or certifications that may assist you in performing the duties of the position for which you are applying. Professional Skills Please indicate areas of proficiency as applicable to the desired position. Microsoft Office Internet Typing – WPM Office Equipment Email Commercial Driver’s License (CDL) Other Other Other Are you an honorably discharged veteran of the United States military? ----YesNo References Please provide three business/professional references who are not related to you and not previous supervisors. If not applicable, please list three school or personal references not related to you. Name and Title Years Known Relationship to You Telephone Number Name and Title Years Known Relationship to You Telephone Number Name and Title Years Known Relationship to You Telephone Number Educational/Training Background Please provide all relevant educational and training background, including certifications and professional licenses. School (City, State) Years Completed Degree/Diploma Subject Completed? ----YesNo School (City, State) Years Completed Degree/Diploma Subject Completed? ----YesNo School (City, State) Years Completed Degree/Diploma Subject Completed? ----YesNo School (City, State) Years Completed Degree/Diploma Subject Completed? ----YesNo Affidavit Please read carefully before signing. I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I understand that Yuma County may conduct a background investigation and that Yuma County will provide for me a separate form authorizing the completion of such an investigation prior to completion. I authorize Yuma County and/or any of its agents to verify and investigate any or all statements contained in this application. I also authorize any person, school, employer, law enforcement authority, or organization named in this application to provide and release any information and opinions concerning my background. I release such persons and organizations from any legal liability for any damage whatsoever for making such statements. I understand that employment decisions at Yuma County are made on a merit basis and are not influenced by race, color, national origin, ancestry, creed, religion, sex, age, physical or mental disability, sexual orientation, or any other similarly protected status. I understand the use of illicit drugs is prohibited during employment. I may be required to successfully pass a drug and alcohol screening examination prior to being hired and consent to taking a drug and alcohol test at any time during my employment should I be hired. I understand that this application or any subsequent employment does not constitute a contract of employment nor guarantee employment for any definite period of time. I certify that I have read, fully understand, and accept all terms listed above.
