ISU Extension and Outreach – Warren County

EMPLOYMENT APPLICATION for Summer 4-H Assistant

An Equal Opportunity Employer

1. Full Name

Last First Middle

2. Telephone Number(s) / ( ) / - / ( ) / -

Area Code/Primary/Home number Area Code/Alternate number

3. Address

Street/P. O. Box/Apt # City State Zip

4. Are you 18 years of age or older? / (Yes/No)
5. Are you legally authorized to work in the United States? / (Yes/No)
6. Have you ever been convicted of a felony? / (Yes/No)
If, yes,* for what, where, and when:

*A criminal conviction is not an absolute bar to employment but will only be considered

in relationship to specific job requirements.

Date Available for Employment

POSITION(S) FOR WHICH YOU ARE APPLYING

Position - One title per line
1.
2.
3.

Each job position has minimum education, experience, and/or ability requirements. It is very important that all of your education and work experience (paid, volunteer or self-employment, such as farming) be listed. Use complete dates (month and year), and one figure for the number of hours worked per week when reporting work experience.

EDUCATIONAL DATA

High School Graduate or Equivalent (GED)? / (Yes/No)
You may be required to provide a transcript
Name and location of high school, college, university, vocational/technical schools / From / To / Degree
(Most Recent First) / Mo / Yr / Mo / Yr / Major or Course Title / AA, AS, BA, BS, MA, MS, CEU’s
a.
b.
c.
EMPLOYMENT DATA

A. If you had more than one position with the same employer, list each separately.

B. If a job was part time, list the average number of hours worked per week.

C. When describing a job, list 3 or 4 major tasks performed and the approximate percentage of time spent on each task.

D. Volunteer work experience will be evaluated in the same manner as paid employment and should be entered the same.

1. EMPLOYMENT HISTORY (Current )

Employer / Type of Business
Employer's Address
Employer’s Phone Number / May we contact this employer?
Your Title / Supervisor's Name
Employed from / / / to / / / Average hours per week employed
month/year / month/year
Reason for leaving
List all machines/equipment/software used on the job:
Amount paid per hour or salary:
Duties: (Be Specific)
(1.) / %
(2.) / %
(3.) / %
(4.) / %

2 EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address
Employer’s Phone Number / May we contact this employer?
Your Title / Supervisor's Name
Employed from / / / to / / / Average hours per week employed
month/year / month/year
Reason for leaving
List all machines/equipment/software used on the job:
Amount paid per hour or salary:
Duties: (Be Specific)
(1.) / %
(2.) / %
(3.) / %
(4.) / %

3. EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address
Employer’s Phone Number / May we contact this employer?
Your Title / Supervisor's Name
Employed from / / / to / / / Average hours per week employed
month/year / month/year
Reason for leaving
List all machines/equipment/software used on the job:
Amount paid per hour or salary:
Duties: (Be Specific)
(1.) / %
(2.) / %
(3.) / %
(4.) / %

4. EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address
Employer’s Phone Number / May we contact this employer?
Your Title / Supervisor's Name
Employed from / / / to / / / Average hours per week employed
month/year / month/year
Reason for leaving
List all machines/equipment/software used on the job:
Amount paid per hour or salary:
Duties: (Be Specific)
(1.) / %
(2.) / %
(3.) / %
(4.) / %
Personal/Professional References Do not include family members
Name / Phone Number / Best Time to Call / Occupation

COMMENTS: State any additional information you feel may be helpful to us in considering your application.

APPLICANT’S STATEMENT

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 in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship within this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge 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 a change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations on the employer.

/ / /

Applicant’s Signature (may be typed if submitting electronically) Date

… and justice for all
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue SW, Washington, DC 20250-9410, or call 800-795-3272 (voice) or 202-720-6382 (TDD). USDA is an equal opportunity provider and employer.