- Employment Application Form

Last

First

Middle Initial

Street

City

State

Zip Code

Daytime Telephone

Cell phone / alternate phone

Position Applying for

Please mark preferred status Full-time Part-time No Preference Other

Date Available (mm/dd/yyyy)

Are you currently employed? Yes No

If Yes, may we contact your current employer? Yes No

Are you over the age of 18? Yes No

If No, can you furnish a work permit? Yes No

Are you willing to work overtime, if necessary? Yes No

Are you a U.S. Military Veteran? Yes No

If Yes, provide proof of elibbility, DD Form 214 or other documents)

Please select a file

**If applying for positions with Human Services; are you claiming Veterans' Preference? Yes No

Have you ever been convicted of a felony or misdemeanor? Yes No

If "yes", provide the date, crime and other relevant information. Criminal convictions will be considered only to the extent relevant to the job duties.

Do you possess a valid driver's license, if driving is an essential function of the job for which you are applying? Yes No

If yes, please provide driver's license number

State Issued

Do you have a legal right to work in the United States? Yes No

Skills and Qualifications

Have you reviewed the job posting? Yes No

Do you possess the skills and qualifications listed in the job posting? Yes No

Please list any other skills and qualifications you possess that would be beneficial to the position

Please upload your resume

Please select a file

Education

High School

Name & Address of School

Course of Study

Number of Years

Did You Graduate? Yes No

Degree or Diploma Received

College

Name & Address of School

Course of Study

Number of Years

Did You Graduate? Yes No

Degree or Diploma Received

Other

Name & Address of School

Course of Study

Number of Years

Did You Graduate? Yes No

Degree or Diploma Received

Work Experience (List in order, last or current employer first)

Employer 1

Name and Address of Company and Type of Business

From (M./Yr.)

To (Mo./Yr.)

Starting Salary

Ending Salary

Reason for Leaving

Name of Supervisor

Describe the work you did:

Employer 2

Name and Address of Company and Type of Business

From (M./Yr.)

To (Mo./Yr.)

Starting Salary

Ending Salary

Reason for Leaving

Name of Supervisor

Describe the work you did:

Employer 3

Name and Address of Company and Type of Business

From (M./Yr.)

To (Mo./Yr.)

Starting Salary

Ending Salary

Reason for Leaving

Name of Supervisor

Describe the work you did:

If you need additional room to complete your Work Experience, use additional sheets of paper.

Please select a file

I hereby give permission to contact the employers listed above concerning my prior work experience.

If there is a particular employer(s) you do not wish us to contact; please indicate which one(s).

Personal References (Not Former Employers or Relatives)

Reference 1

Name, Occupation

Years Known

Address

Telephone Number

Reference 2

Name, Occupation

Years Known

Address

Telephone Number

Reference 3

Name, Occupation

Years Known

Text area

U.S. phone number

I authorize Susquehanna County to complete a criminal background check, check references and verify information provided in the employment process. I consent to a pre-employment drug test and I understand that if I am given an offer of employment it will be conditioned upon my completion of a medical examination / psychological examination (if applicable).

Signature of Applicant

By typing your name in this box you are electronically signing this application.

Date

Applications will be retained for one (1) year from the date received, after which applicant must reapply.

In complying with the New Hire Provisions of the Personal Responsibility and Work Opportunity Act of 1996, we will furnish the name, address, social security number, date of birth and date of hire of any applicant that is hired to the Commonwealth of PA Department of Labor and Industry.

This application is available in other formats. Applicants requiring accommodation in the application or hiring process should contact the Human Resource Department.

**Veterans' Preference

You may receive preference in hiring if you are: a veteran, the widow or widower of a veteran, or the spouse of a disabled veteran. Your separation must have been under Honorable or other acceptable conditions.

The following documents will need to be submitted with your application:

Veterans: Photocopy, not the original, of the DD Form 214 or other military document showing dates of entry and separation and character of service.
Widow and Widowers: Photocopy, not the original, of the spouse's DD Form 214. A certified copy (not a photocopy) of the death certificate.
Spouses of Disabled Veterans: Photocopies, not the originals, of DD Form 214; a Veterans' Administration letter, dated within the past six months, verifying that the veteran is receiving compensation for a service-connected disability; and a signed statement from the disabled veteran showing the social security number and agreeing to transfer credit to you.