Employment Application

Contact Information

1. First Name
2. Middle Name
3. Last Name
4. Address
5. City
6. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7. Zip
8. Phone
9. Alternate Phone
10. Email
11. Position you are applying for: Choose an open position. Director / Administrator of Veterans Affairs
12. Date Available
13. Are you 18 or older? Please Select Yes No
14. Do you have a legal right to work in the United States full-time? Please Select Yes No
15. Have you ever been employed by Jasper County? Please Select Yes No
Employed Start Date:
Employed End Date:
Employed Position
Reason for Leaving
16. Do you have relatives employed by us? Please Select Yes No
If yes, please list the relatives.
17. How did you learn about this job opening?

Education

High School

18. Name and Location
19. Did you graduate? Please Select Yes No No, but received GED

College or Trade School

20. Name and Location
21. Did you graduate? Please Select Yes No
22. Major/Subject

Employment History

List employment from the past 10 years, starting with your most recent job. Account for any time period that you were unemployed by stating the nature of your activities.

Employer 1

23. Employer Name
24. Job Title
25. Address
26. City
27. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
28. Zip
29. Phone
30. Start Date
31. End Date
32. Current/Ending Pay
33. Supervisor Name
34. Work Performed
35. Reason For Leaving
36. Can we contact current employer? Please Select Yes No
Add Employer

Employer 2

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor Name

Work Performed

Reason For Leaving Add Employer

Employer 3

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor

Work Performed

Reason For Leaving

Additional Employers
37. Have you ever been discharged from a job? Please Select Yes No
If yes, please list the employer, dates, and provide an explanation

Optional: Upload Resume

38. Resume
    only PDF files are allowed

References

Please list three personal references, other than prior employers or relatives, whom we can contact.

Reference 1

39. Name
40. Phone
41. How long have you known this reference?
42. Occupation

Reference 2

43. Name
44. Phone
45. How long have you known this reference?
46. Occupation

Reference 3

47. Name
48. Phone
49. How long have you known this reference?
50. Occupation

Military Services

51. Were you in the Military? Please Select Yes No

Chapter 35C of the Code of Iowa provides certain rights including preference in hiring if equally qualified to certain Veterans of United States Military Service. Qualification for these rights is defined in the statute.

Dates of service
Branch
Final Rank
Please list training and work performed in the military.
Any person who may wish to claim a Veterans Preference must submit a copy of a certified form DD214 by the deadline set for the receipt of applications for the position for which the person is applying.
Upload DD214 Form
only PDF files are allowed

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Additional Information

52. List any professional, trade groups, organizations, machinery/tools operated in the past, and/or special skills that you consider relevant to your ability to perform this job.
    
    This may also include relevant professional licenses. if listing licenses, please include the license type, certificate number, state of issue, and expiration date.
53. Have you ever been convicted of a felony?
    For purposes of these questions, convicted includes plead guilty, plead no contest, or been given a deferred sentence of judgment. Please Select Yes No
If yes, please explain.
Note: A conviction will not automatically disqualify an applicant for a particular job and that the type and seriousness of the crime, the frequency of violoations, the date of conviction, and the applicant's entire work and educational history will be considered.

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Job Description

54. Have you read the job description? Please Select Yes No
55. Do you understand the requirements? Please Select Yes No
56. Can you perform the requirement of this job with or without reasonable accommodations? Please Select Yes No

Driver's License

57. If the job requires, do you have the appropriate valid driver's license? N/A Yes No
Driver's License #
License Type
State of License Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Have you had any moving violations? Please describe:

Abuse Registry and Criminal History Waiver

I hereby give permission for Jasper County, Iowa to conduct a child and/or dependent adult abuse check and an Iowa criminal history check with the Division of Criminal Investigation. Any information maintained by DCI may be released and I understand that it will be used by the requestor only for licensing, employment or volunteer purposes.

58. Signature Please type your full name to serve as an electronic signature.
59. Date

Confidential Information

As required, we comply with government regulations including Affirmative Action obligations where they apply.

In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you complete this applicant survey. Your cooperation is appreciated.

Please be advised that your survey is not part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.

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60. Please select one. American Indian or Alaskan Native: persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.
    White, not of Hispanic Origin: persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
    Black, not of Hispanic Origin: persons having origins in any of the Black racial groups of Africa.
    Asian, or Pacific Islander: persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.
    Hispanic: persons of Mexican, Puerto Rican, Cuban, Central of South America, or other Spanish culture or origin, regardless of race.
    Other

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61. Gender Please Select Male Female

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62. Disabled/Veteran Classifications Disabled Person: Federal regulation defines a disabled person as one who (1) has a physical or mental impairment which substantially limits one or more of such person's major life activities, (2) has a history of such impairment, or (3) is regarded as having such an impairment
    Vietnam Veteran: Federal regulations define a veteran of the Vietnam Era as one who (1) served on active duty for a period of more that 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released with other than a dishonorable discharge, (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964 and May 7. 1975.
    Special Disability Veteran (30% or more disability): Federal regulations defines a special disabled veteran as one who (1) is entitled to compensation under laws administered by the Veterans' Administration for disability rated 30% or more, (2) was discharged or released from active duty because of a service-connected disability.
    

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this Application for Employment as may be necessary in arriving at an employment decision.

I authorize Jasper County to conduct a check of the status of my driver’s license and my driving record and agree to sign an authorization for this specific purpose.

This Application for Employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Jasper County is “at will” nature, which means that the Employee may resign at any time, and the Employer may discharge the Employee at any time with or without cause. It is further understood that the “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of Jasper County.

I understand that any offer of employment that is extended to me is considered to be a conditional offer and is subject to successful completion of all required background checks. Identifying information such as my social security number and driver’s license number will be requested at the post-offer, pre-employment stage.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge, also, that I am required to abide by all rules and regulations of the Employer.

I agree to give Jasper County permission to complete appropriate background checks and agree to sign permission/authorization documents so that this can be accomplished.

Your Signature

63. Signature Please type your full name to serve as an electronic signature.
64. Today's Date