Huntington, West Virginia 25701
(please print in ink or type)
Length of Time at Present Address __________________Telephone: Home _____________________ Work ___________________
_________________________________________________________________________________________
Previous Address City State Zip How Long?
Are you over 18 years of age? Yes _____ No _____ How Did You Learn of This Opening____________________________
Are you legally eligible for employment in this country: Yes ____ No ____ Date Available for Employment ___________________
Do you have a valid driver’s license? Yes _____ No _____
Have you ever worked for the County? Yes _____ No _____ When? _______________ Where?___________________________
Yes _____ No _____ Are you a U. S. Veteran?
Yes _____ No _____ Are you a member of the National Guard or Reserves?
If you answer YES to any of the following questions, please give particulars on the back of this application. A YES ANSWER DOES NOT AUTOMATICALLY DISQUALIFY YOU FROM CONSIDERATION.
Yes _____ No _____ Have you ever been discharged or asked to resign from employment?
Yes _____ No _____ Have you ever been convicted of a crime other than a traffic violation?
Yes _____ No _____ Do you object to inquiry of your present employer in regard to your character, work record, qualifications or
abilities?
Graduate: Yes ______ No ______ General Equivalency Diploma (GED): Yes ______ No ______
Name and Location of College/University Attended: ______________________________________________________
Major/Minor: ____________________________________________________________ Graduate: Yes ______ No ______
List Other Special Skills, Training or Knowledge: __________________________________________________________________
_________________________________________________________________________________________
EMPLOYMENT HISTORY:
Company Name:_____________________________________________________Phone:__________________________
Address:___________________________________________________________________________________
Position and Nature of Duties: ____________________________________________________________________
_________________________________________________________________________________________
Date of Employment: From ____________________ To _____________________ Salary: _________________________
Supervisor’s Name:____________________________ Reason for Leaving:_______________________________________
Company Name:____________________________________________________Phone:___________________________
Address:____________________________________________________________________________________________________
Position and Nature of Duties:___________________________________________________________________________________
__________________________________________________________________________________________
Date of Employment: From_____________________ To_____________________ Salary: _________________________
Supervisor’s Name:____________________________ Reason for Leaving:_______________________________________________
Company Name: _____________________________________________Phone:______________________________
Address:___________________________________________________________________________________
Position and Nature of Duties:_____________________________________________________________________
_________________________________________________________________________________________
Date of Employment: From____________________ To______________________ Salary: _______________________
Supervisor’s Name: ___________________________ Reason for Leaving:_______________________________________________
(If you do not have sufficient space to give a complete record, attach an additional sheet and continue)
References (Do not list relatives)
Name Address Telephone No.
1.________________________________________________________________________________________
2.________________________________________________________________________________________
3.________________________________________________________________________________________
APPLICANT STATEMENT
I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.
If the position
for which I am applying requires a license and or certification, I understand
that it is my responsibility to supply a copy of the license and or
certification to the appropriate department(s). I also understand that it is my
responsibility to keep this license and or certification current and in good
standing.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered.
I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions, criminal records, motor vehicle records and to otherwise verify the accuracy of all information provided by me in this application, resume’ or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.
In consideration of my employment, I agree to conform to all applicable policies and procedures as amended from time to time. I understand that in accepting this application, the County is in no way obligated to provide me with employment and that I am not obligated to accept employment, if offered.
If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice (“at will employee”). This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the Cabell County Commission.
I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.
I CERTIFY THAT I HAVE READ, FULLY UNDERSTAND, AND ACCEPT ALL TERMS OF THE FOREGOING APPLICANT STATEMENT.
Signature of Applicant__________________________________________________________ Date______________________