Employment Application

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Date

MM slash DD slash YYYY

Name*

First Middle Last

Street Address*

City*

State*

Zip*

Phone*

Email*

Is any additional information concerning change of name, use of an assumed name or nickname necessary, to enable a check on your work and education record?*

Yes

If yes, please explain.*

Indicate below all employment positions that you wish to be considered for:

Full Time

Part Time

Sheriff’s and/or Jail Department

Parks and Recreation

County Highway

Government Office – Auditor; Assessor; Clerk; Courts; Recorder; Treasurer

Community Corrections and/or Probation

Prosecutor’s Office and/or Public Defender’s Office

Health Department

Other

If you selected other, please describe.*

Current CDL?

Yes

Willing to obtain

When are you able to start work?*

Employment History

Employers

Begin with current or most recent employer. Click the

icon to add another.

Company

Address

City, State, Zip

Telephone

Position

Supervisor

Start Date

End Date

Reason for Leaving

Depending upon the position you are applying for: If an essential job function requires heavy lifting (50-75 pounds) is there anything that would prevent you from performing this function?*

Yes

If yes, please explain.*

References

Professional/Working References

Please provide 3. Click the

icon to add another.

Name

Address

City, State, Zip

Telephone

Personal References (No Relatives)

Please provide 3. Click the

icon to add another.

Name

Address

City, State, Zip

Telephone

Have you ever been employed by Decatur County before?*

Yes

If yes, please provide approximate dates and position(s).*

Educational Background

Click the

icon to add another school.

School

Years Attended/Graduated

Degree earned? When?

Agreement

I certify that the information given in this application is true and complete to the best of my knowledge.

I authorize you to make such investigations and inquiries as may be necessary in arriving at an employment decision. I hereby release employers, schools, or persons from all liability in responding to inquiries in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) or any omission of information may result in discharge. I understand, also, that I am required to abide by all rules and handbook policies of Decatur County Government &/or the specific department.

Signature of Applicant*

Questionnaire

In order to be considered for employment by the recipient(s) of the application, you must fully complete the following questionnaire and sign it.

Are you presently being investigated or under a procedure to consider for your discharge for misconduct by your present employer or have you offered a resignation to your previous employer?

Yes

If yes, please explain the circumstances.*

Have you ever been reprimanded, disciplined, discharged, or asked to resign from a prior position?

Yes

If yes, please explain the circumstances.*

Have you ever resigned from a prior position without being asked, but under circumstances involving your employer’s investigation of your sexual contact with another person, of mishandling funds, or of criminal conduct resulting in a conviction or criminal penalty?

Yes

If yes, please explain the circumstances.*

Have you ever been convicted of a Felony?

Yes

If yes, explain, in detail, including the date of the charge, the court action, the offense in question, and the address of the court involved.*

Are you currently required to register as a sex offender in this or any other jurisdiction?

Yes

If yes, explain, in detail, including the date of the charge, the court action, the offense in question, and the address of the court involved.*

Conviction of a crime is not an automatic bar to employment. The recipient(s) of this application will consider the nature of the offense, the date of the offense, and the relationship between the offense and the position for which you are applying.

Any false or misleading information in this application (or any omissions of information) shall be fully sufficient grounds to refuse to employ or, having been employed, shall be immediate cause for dismissal.

My signature below constitutes authorization to check my employment history, including without limitation, evaluations, criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any state, local or federal agency. I further authorize those persons, agencies or entities that the recipient(s) of this application contacts in connection with my employment application to fully provide the recipient(s) of this application any information on the matters set forth above. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the recipient(s) of this application, its agents and officials or against any provider of such information.

EEO The government of Decatur County, Indiana does not discriminate on the basis of race, color, gender, National origin, age, religion, gender identity, veteran or disability status in employment or the provision of services.

Signature of Applicant*

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