Waupaca Application Form – Fill Out and Use This PDF

EMPLOYMENT HISTORY

Give a complete record of any employment, self-employment, military service or volunteer experience you have had in the past 10 years. Please include positions beyond the 10 year period if they are related to the position for which you are

applying. Start at the top with your present or most recent job. Indicate any change in job title under the same employer as a separate position. Please note that it is the policy of Waupaca County to contact an applicant’s current employer only after

that applicant has been deemed a finalist for a position.

Name of Employer	Telephone				Employed (Mo.& Yr.)
	(	)	-		From	To
Address					Hours per Week
Name of Supervisor/Title:	May we contact?				Did you have Supervisory
	Yes	฀	No	฀	Responsibilities? Yes ฀		No	฀
					If yes, # Supervised: _____
Your Job Title:					Reason for Leaving:
Describe Your Work:
Name of Employer	Telephone				Employed (Mo. & Yr.)
	(	)	-		From	To
Address					Hours per Week
Name of Supervisor/Title:	May we contact?				Did you have Supervisory
	Yes	฀	No	฀	Responsibilities?	Yes ฀	No	฀
					If yes, # Supervised: _____
Your Job Title:					Reason for Leaving:
Describe Your Work:
Name of Employer	Telephone				Employed (Mo. & Yr.)
	(	)	-		From	To
Address					Hours per Week
Name of Supervisor/Title:	May we contact?				Did you have Supervisory
	Yes	฀	No	฀	Responsibilities?	Yes ฀	No	฀
					If yes, # Supervised: _____
Your Job Title:					Reason for Leaving:
Describe Your Work:
Name of Employer	Telephone				Employed (Mo. & Yr.)
	(	)	-		From	To
Address					Hours per Week
Name of Supervisor/Title:	May we contact?				Did you have Supervisory
	Yes	฀	No	฀	Responsibilities?	Yes ฀	No	฀
					If yes, # Supervised: _____
Your Job Title:					Reason for Leaving:
Describe Your Work:

(For additional employers, please use a separate piece of paper)

Explain any gaps in employment:

PROFESSIONAL OR CIVIC ORGANIZATION MEMBERSHIP

List professional, trade, business or civic activities and office held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:

ADDITIONAL INFORMATION

Please provide any other information which you feel pertinent to this application:

Waupaca County requires a pre-employment physical examination and for certain positions a pre-employment drug test may be required. Waupaca County reserves the right to test all applicants for job related skills.

AUTHORIZATION AND SIGNATURE

I hereby certify that the answers given by me to the questions and statements on this application are true and correct. I hereby authorize the County to contact references, past or present employers, persons, schools, law enforcement agencies and other sources of information, which may be relevant to my application for employment.

This application is good only for the position I am applying for at this time. To be considered for future positions, a new application must be completed at the time the position is being recruited.

Employees of Emergency Management Department, Sheriff’s Office, and Highway Department (excluding the Highway Department’s clerical and engineering staff) must become residents of Waupaca County. Failure to comply with this

condition of employment within the time frame allowed will result in termination.

It is understood and agreed that any misrepresentation, false statement or omissions by myself in this application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to the County.

Persons offered certain positions may be required to pass a drug/alcohol, medical, physical fitness, psychological, criminal background check, or other job related examination.

I hereby acknowledge that I have read and understand the statements above.

Applicant’s Name (Print)

Applicant’s Signature:		Date:

If you need any special accommodations for an interview, please request this in advance. Thank you for completing this application and for your interest in employment with Waupaca County.