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APPLICANT INFORMATION

Applicant Name: *
(Last, First, Middle Initial)
Which position are you applying for: *
Mailing Address:*
(Include City, State, Zip)
Physical Address:*
(Include City, State, Zip)
Email Address:*
Phone Number:*
Alternate Phone Number:
Are you eligible to work in the United States?*
1. Yes
1. No
Have you ever previously been employed by Blaine County? *
1. Yes
1. No
If yes, when and what position?
Do you have any relatives employed by Blaine County? *
1. Yes
1. No
If yes, employee's name, relationship, and position.
Upload Your Resume:*
Upload Cover Letter:
Type of work you are seeking.*
1. FULL-TIME
1. PART-TIME
1. TEMPORARY
Mark which shifts you are willing to work.*
1. DAY-SHIFTS
1. NIGHT-SHIFTS
1. ROTATING SHIFTS
1. WEEKENDS
Date you are available to start?*
Salary desired:*
Do you have a valid Driver's License? *
1. Yes
1. No
Driver's License # and State Issued:*
Name Used and Expiration Date:*
Have you ever been convicted of a violation of the law other than a minor traffic violation? *
1. Yes
1. No
Have you ever been convicted of a felony?*
1. Yes
1. No
If yes, please explain and include dates:
How did you hear about the position?*
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EDUCATIONAL HISTORY

EMPLOYMENT HISTORY

List your work history below, going back at least ten (10) years, beginning with your current or most recent job. You must provide current contact information for all employers or supervisors.
Employer's Name *
Employer's Address with City, State, and Zip*
Title / Position you held*
Time of Employment*
Time of Employment Start Date
—
Time of Employment End Date
Specific Responsibilities and Duties*
Starting and Ending Salary*
Supervisor's Name*
Phone Number*
May we contact this supervisor for a reference?*
1. Yes
2. No
Specific Reason for Leaving *
Employer's Name
Employer's Address with City, State, and Zip
Title / Position you held
Time of Employment
Time of Employment Start Date
—
Time of Employment End Date
Specific Responsibilities and Duties
Starting and Ending Salary
Supervisor's Name
Phone Number
May we contact this supervisor for a reference?
1. Yes
2. No
Specific Reason for Leaving
Employer's Name
Employer's Address with City, State, and Zip
Title / Position you held
Time of Employment
Time of Employment Start Date
—
Time of Employment End Date
Specific Responsibilities and Duties
Starting and Ending Salary
Supervisor's Name
Phone Number
May we contact this supervisor for a reference?
1. Yes
2. No
Specific Reason for Leaving
Computer Experience
Describe the types of computer equipment and software programs you have used and your level of experience with each.
Specialized Training
List any specialized training, apprenticeship, skills, extracurricular activities, and additional schooling or educational awards you may have.
Other Experiences
Summarize any other experience, volunteer work, or any related general information; including any licenses or technical skills; professional, trade, business, or civic activities and offices you have held.
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REFERENCES

List three professional references
Reference Name*
Place of Employment *
Occupation*
Years Known*
Relationship*
Phone Number*
Email Address*
Reference Name*
Place of Employment *
Occupation *
Years Known*
Relationship*
Phone Number*
Email Address*
Reference Name*
Place of Employment*
Occupation *
Years Known*
Relationship*
Phone Number*
Email Address*
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MILITARY HISTORY

List military history information below
Have you ever served in the U.S. Military? *
1. Yes
1. No
If yes, please complete the next sections of information:
Branch
Dates of Service
Dates of Service Start Date
—
Dates of Service End Date
Rank at Discharge:
Type of Discharge:
If other than honorable, please explain:
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ADDITIONAL INFORMATION

Additional Information
Use this section to provide any additional information that you feel is applicable in answering the questions asked in this application that require detailed answers. List the corresponding page name (i.e. References). Should you need additional space, please upload the documents below.
Additional information
Please upload documents
Letters of Recommendation
Please upload documents
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APPLICANT SIGNATURE

I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary for arriving at an employment decision. I also consent to a background investigation and reference check. This application for employment shall be active for some time, not to exceed 45 days. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at-will” nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is further understood that this “at-will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge at any time. I understand, also, that I am required to abide by all rules and regulations of the employer.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
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APPLICANT INFORMATION

EDUCATIONAL HISTORY

EMPLOYMENT HISTORY

REFERENCES

MILITARY HISTORY

ADDITIONAL INFORMATION

APPLICANT SIGNATURE

BLAINE COUNTY APPLICANT VOLUNTARY SELF IDENTIFICATION FORM

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