Employment Application

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Specify the position for which you are applying. (Note: A separate resume may be attached.)

Last Name

First Name

M. Initial

Social Security Number

Street Address

Home Phone

Cell Phone

Business Phone

Email Address

Name / Location of School

Received:

Diploma None Other

Name of School

Location

Dates of Attendance

Credit Hours Earned

Major/Minor/Course of Study

Type of Degree Earned

Job-Related Training or Course Work

Name of School

Location

Dates of Attendance

Credit Hours Earned

Course of Study

Training Completed?

Yes No

Licensure, Resignation, Certification

Number

Date Received

Expiration Date

State Licensing Agency

Knowledge / Skills / Abilities

List KSAs you possess and believe relevant to the position you seek, such as operating heavy equipment, computer skills, fluency in language(s), etc.

Branch of Service

Special skills / training acquired while in the service:

Date of Entry

Date of Discharge

Driver's License?

Yes No

Type of License

Operator Commercial CDL Chauffeur Other

Driver's License Number

State of Issue

What is your means of transportation to work?

Have you had any accidents during the past three years?

Yes No

Have you had any moving violations during the past three years?

Yes No

Work Experience

Most recent first.

Employer

Phone Number

Job Title

Number Employees Supervised

Specific Duties

Last Salary

Reason for leaving?

May we contact this employer?

Yes No

References

Please list two references other than relatives or previous employers

Name

Company

Position

Address

Phone Number

Name

Company

Position

Address

Phone Number

Do you have any physical limitations that preclude you from performing any work for which you are considered?

Yes No

In case of emergency, please notify

Name

Phone Number

Address

I am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for employment consideration and, if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel staff, and other authorized employees of Cape Girardeau County government for employment are purposes. This consent shall continue to be effective during my employment if I am hired. I understand that applications submitted for county employment are public records except as exempted above. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and in good health.