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This document is prepared for exclusive use of Waggoner, Irwin, Scheele & Assoc., Inc., aud shall not be duplicated without written consent. 82013 / Rev 08/2016 A-1 APPLICATION FOR EMPLOYMENT County of Marshall, Indiana an Equal Opportunity Employer The County of Marshall, Indiana, does not discriminate on the basis of race, color, gender, national origin, age, religion, or disability, in employment or the provision of services. Please type or print responses to all questions on the application form. Any application not completed in its entirety will be disqualified. Position sought: Last name First name Middle initial Former name(s) Address City/state/zip Phone Email Address Are you at least 18 years of age? Yes: No: Applicants for Sheriff Department: Are you at least 21 years of age? Yes: No: Are you related to an employee currently employed by the County? If yes, please state relationship Yes: No: Are you interested in: Full-time work? Part-time work? Temporary work? Date available to start work Yes No Yes No Yes No ******************************************************************************* EMPLOYMENT HISTORY AND WORK EXPERIENCE List all employment history and work experience during the previous five years, beginning with your current employer. Failure to include all past employment may be grounds for disqualification. If currently unemployed, check here and skip to Previous employer below. Current employer Address City/state/zip
A-2 This document is prepared for exclusive use of Waggoner, Irwin, Scheele & Assoc., Inc.. and shall not be duplicated without written consent. 82013 / Rev 08/2016 Phone Hire date Job title Beginning salary per Current salary per Supervisor Title Work phone Briefly describe the work you do, such as duties, responsibilities, equipment you operate, promotions: Why do you want to leave? May we contact your current employer? Yes: No:If no, please explain why: Previous employer Phone Address City/state/zip Dates employed Job title Beginning salary per Ending salary per Supervisor Title Work phone Briefly describe the work you do, such as duties, responsibilities, equipment you operate, promotions: Reason for leaving: May we contact your current employer? Yes: No:If no, please explain why: Previous employer Phone Address City/state/zip Dates employed Job title Beginning salary per Ending salary per Supervisor Title Work phone
A-3 This document is prepared for exclusive use of Waggoner, Irwin, Scheele & Assoc., Inc.. and shall not be duplicated without written consent. 82013 / Rev 08/2016 Briefly describe the work you do, such as duties, responsibilities, equipment you operate, promotions: Reason for leaving : May we contact this employer? Yes: No:If no, please explain why: Previous employer Phone Address City/state/zip Dates employed Job title Beginning salary per Ending salary per Supervisor Title Work phone Briefly describe the work you do, such as duties, responsibilities, equipment you operate, promotions: Reason for leaving: May we contact this employer? Yes: No:If no, please explain why: If you had additional employers within the last five years, attach additional pages as needed. List and explain periods of unemployment in the past five years: From to Reason: ________________________________________________________________________________ _ From to Reason: ________________________________________________________________________________ _
A-4 This document is prepared for exclusive use of Waggoner, Irwin, Scheele & Assoc., Inc.. and shall not be duplicated without written consent. 82013 / Rev 08/2016 **************************************************************************************** EDUCATION AND TRAINING This section is intended to give the employer information about education and training you have completed, and to describe your skills, knowledge, and abilities to perform the duties of the position. High school attended. Attach additional pages as needed. Name Address City/state/zip Diploma? Yes NoGED? Yes No Activities, awards (You may exclude any ·which indicate race, color, religion, gender, age, national origin, or disability) College(s) or Trade School(s) attended. Attach additional pages as needed. Name Dates attended to Address City/state/zip Degree(s) Major/minor course(s) of study Name Dates attended to Address City/state/zip Degree(s) Major/minor course(s) of study Activities, awards (You may exclude any which indicate race, color, religion, gender, age, national origin, or disability.) Seminars/workshops, special awards, articles you have published, and other information that may be relevant to the position you are seeking:
A-5 This document is prepared for exclusive use of Waggoner, Irwin, Scheele & Assoc., Inc.. and shall not be duplicated without written consent. 82013 / Rev 08/2016 ************************************************************************************** MILITARY HISTORY AND STATUS If you have never served in the military on active duty, check here and skip to the next section. Military Branch Dates of Service Highest Rank Attained Rank at Separation Type of Discharge Citations/awards received ************************************************************************************* PROFESSIONAL OR SPECIALIZED TRAINING Specialized training Professional/special license(s) or certificate(s): State Issued By Date Issued Expiration Type License # Have you had any license suspended, revoked or terminated? Yes NoIf yes, explain: ************************************************************************************* PROFESSIONAL AFFILIATIONS List current or previous affiliations/organizations and related offices/positions. Organization Name Address Phone Offices/Positions
This document is prepared for exclusive use of Waggoner, Irwin, Scheele & Assoc., Inc., and shall not be duplicated without written consent. 82013 / Rev 08/2016 A-6 Use the following space to describe other training, education, skills, abilities, hobbies, volunteer work or other information that may be helpful in evaluating your application. (You may exclude any which indicate race, color, religion, gender, age, national origin or disability.) ************************************************************************************ PERSONAL INFORMATION Do you have any commitments which might interfere with or adversely affect your employment with us, such as a second job or school? Yes No If yes, please explain: Have you ever been convicted of a felony that has not been expunged or sealed? Yes No If yes, please explain: Do you have an arrest record that has not been expunged or sealed? Yes No If yes, please explain: Are you currently required to register as a sex offender in this or any other jurisdiction? Yes No If yes, please explain (including jurisdiction of registry): List three references who are not related to you and are not former employers or supervisors: Name Phone Address City/state/zip Number of years known
This document is prepared for exclusive use of Waggouer, Irwin, Scheele & Assoc.. Inc.. and shall not be duplicated without written consent. 82013 / Rev 08/2016 A-7 Name Phone Address City/state/zip Number of years known Name Phone Address City/state/zip Number of years known ************************************************************************************ APPLICANT CERTIFICATION Read each of the following paragraphs carefully. Indicate your understanding of, and consent to, the contents and conditions of each paragraph by signing your initials at the end of each paragraph. If you have any questions regarding these paragraphs, contact the employer before initialing. Initials: I understand and accept that, if I am hired, I may be hired conditional on passing any medical and/or psychological examinations that the employer deems necessary to determine my ability to perform the essential functions of the position. I understand and accept that this may include drug, alcohol or substance abuse testing. Initials: I understand that it may be necessary for me to approve and sign any waivers necessary in order for the employer to obtain information from my current and former employers. Initials: I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that, if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded. Initials: I solemnly swear that all of the information furnished in this employment application is true, accurate and complete to the best of my knowledge. I authorize investigation of all statements contained in this application. I understand that my misrepresentations or falsification of the information provided may lead to withdrawal of an employment offer or termination following employment. Initials:
This document is prepared for exclusive use of Waggoner. Irwin. Scheele & Assoc., Inc., and shall 1101 be duplicated without wrillen consent. 82013 / Rev 08/2016 A-8 By submitting this document, I hereby agree that I shall execute the employer's conditional and post- employment medical examination and drug testing consent requirements. I recognize that my future employment with the employer will be jeopardized if I engage in substance abuse, illegal drug use, or alcohol abuse. Applicant's signature Date
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The following sections to be completed by Sheriff Department applicants only: I understand that the employer provides sheriff service on a seven day per week and twenty-four hour per day service, and therefore, if employed by the Sheriff Department , I may be required to work evening shifts or night shifts, including weekends. Initials: I understand that if I am hired as a sworn officer on the Sheriff Department, that I must successfully complete required training and courses specified and be certified by the State of Indiana Police Academy. Initials:
C-1 This document is prepared for exclusive use of Waggoner, Irwin, Scheele & Assoc., Inc., and shall not be duplicated without written consent. ©2011 County of Marshall, Indiana an Equal Opportunity Employer I, respectfully request and authorize to complete a criminal background check. This information is to be used in the course of my application for employment with the County of Marshall. I hereby release , the County of Marshall and any organization assisting with the application process from any liability or damages which may result as a result of furnishing the information requested. Signature of Applicant Date
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Print Full Name Social Security Number Date of Birth (Note: date of birth is requested in order to obtain accurate retrieval of records.) Current Address City/State/Zip Driver's License No. State NOTICE AUTHORIZATION AND RELEASE FOR CRIMINAL BACKGROUND CHECK
County of Marshall, Indiana an Equal Opportunity Employer Marshall County is committed to maintaining a drug free workplace. A drug screen test to detect the use of illegal substances is part of our hiring process. This form must be completed, signed, dated, and when instructed to do so, taken to the Holm Clinic, Plymouth, Indiana, where the test(s) will be administered. I understand that the test may be hair, oral fluids, urine, breath and/or blood and that my signature below indicates my consent and authorization to have my hair, oral fluids, urine, breath and/or blood screened for illegal drugs or substances as a condition of hiring as well as a condition of maintaining employment. I hereby consent to have the results of my hair, oral fluids, urine, breath and/or blood drug screening reported to the appropriate individuals at the Marshall County Sheriff Department and/or Marshall County Government. I understand that if I refuse to submit to this drug screen, or at any time have a positive result to any test I can be terminated from employment. I will not hold harmless Marshall County Government, any testing laboratory that may be used. This means I will not sue or hold responsible such parties for any alleged harm to me that might result from testing, including rescinding any offer of employment, continuing employment, obtaining any promotions or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if Marshall County or the laboratory performing the test makes an error in the administration or analysis of the test or the reporting of the results Signature of Employee or Applicant Date
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Printed Name Personnel Policies Handbook Section 5.9 Revised 04120/2016 D-1 Pre-Employment Drug Screen Request And/or Employment Drug Screening Request