GRAFTON COUNTY - Application for Employment

GRAFTON COUNTY -Application for Employment

~ An Equal Opportunity Employer ~

Consistent with federal and/or state laws, Grafton County does not discriminate in employment and applications for employment because of sex, age, race, color, marital status, religious creed, sexual orientation, national origin, ancestry, service in the armed forces of the United States, disability, genetic make-up or other protected classification. Applicants are subject to a criminal record check and testing for illegal drug use. Individuals applying for positions in the nursing home and the maintenance department are subject to testing for tuberculosis and must pass a pre-employment physical. Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation for the application and/or interview process should notify a representative of the Human Resources Department.

PLEASE PRINT – COMPLETE ALL SECTIONS – INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

Position(s) applied for: ______Date:______

Name: ______Email: ______

LAST FIRST MIDDLE

Address: ______

STREET CITY STATE ZIP CODE

Telephone #: (______)______Mobile/Beeper/Other: (______)______

If necessary, the best time to call you at home is: ______

Are you applying for full-time or part-time employment? ______

If part-time, number of hours desired per week: ______Are you available on weekends? ______

Are you available to work holidays? ______Days of the week you are available: ______

Shifts you are available to work: (e.g., 7 AM -3 PM) ______Are you available to work nights?* ______

Are you available to work overtime? ______If hired, what date could you start work? ______

Are you available to travel on company business?* ______

Hourly rate of pay or monthly salary desired: ______

Are you under the age of 18? ………………………………………………………………….…… Yes ____ No ____

Are you a U.S. citizen or legally eligible for employment in this country? …………………….. Yes ____ No ____

Note: If you are hired, you will be required to provide proof of your identity and authorization to work in the U.S. before

you commence work with us.

Have you applied for employment with Grafton County before? …………………………….… Yes ____ No ____

If yes, when? ______

How did you hear about this position? (newspaper, web, employee, friend/family, walk-in, etc.)

If employee, employee’s name: If newspaper, which one:

Have you ever been employed by Grafton County? ………………………………………..….. Yes ____ No ____

Are you able to meet the attendance requirements of this position? …………………………. Yes ____ No ____

* If required for the position you are seeking.

Do you have any relatives working for Grafton County? ……………………………………..... Yes ____ No ____

If yes, state name and relationship: ______

Have you ever been convicted of or pleaded no contest to a felonywhich has not been annulled by a court? …………………………………………………...... ………………… Yes ____ No ____

Have you ever been convicted of or pleaded no contest to a misdemeanor which has not been annulled by a court? …………………………………………………………………. Yes____ No _____

If yes, please describe fully the conviction(s), listing the nature of each offense, the date of each offense, the sentence imposed for each offense, the court(s) in which you were convicted and any mitigating circumstances you might wish us to know.K8______

Note: A conviction record will not necessarily be a bar to employment. Factors such as your age at the time of the offense, the seriousness and nature

of the offense, rehabilitation, and the relation of the offense to employment will be taken into account.

If applying for a nursing position, you must answer the following 4 questions:

In this State, you must have an active NH license issued by the NH Board of Nursing for employment in a LNA, MNA, LPN or RN position. Do you have a current NH license? Yes______No______

If no, explain how you plan to meet this requirement: ______

In this state or any other state, have you ever been convicted of or pleaded guilty to resident mistreatment, abuse, neglect or misappropriation of resident property that has not been annulled by a court? Yes ____ No_____

If yes, fully describe the conviction(s), listing the nature of the offense, the date and place of the conviction, the underlying circumstances and any period of imprisonment or probation.

______

In this state, any other state or in any other U.S. or foreign jurisdiction, have you ever been subject to disciplinary action or sanctions by a healthcare licensing agency or Medicare/Medicaid? Yes ___ No ___

If yes, fully describe the nature, date and place of the action, the agency involved and the underlying circumstances.

______

Are you listed in any resident or patient abuse registry in this state or any other state? Yes ___ No ___

If yes, explain fully: ______

Do you have a valid Driver’s License if driving is an essential job function: Yes______No_____ State: ______

Skills and Qualifications: Summarize any special training, skills, licenses and/or certificates that may qualify you as being able to perform job related functions in the position for which you are applying.

______

Employment History: Provide the following information for your past and current employers, starting with the most recent. Explain any gaps in employment in the comments section on the next page.

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FROM: (Month/Year) TO: (Month/Year) / Employer Telephone #
Position Held / Street Address City State
Immediate supervisor & title / Summarize the nature of work performed and job responsibilities
May we contact for references?
Yes No Later / Compensation: Hourly Salary
Start $ Per Final $ Per / Commission:
Bonus:
Reason for leaving:

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Comments: (including explanation of any gaps in employment) ______

______

Educational Background: List last three schools attended, most recent first.

School / # Of Years Completed / Degree or Diploma / GPA or
Class Rank / Major / Minor

References: List names and telephone numbers of three business/work references who are notrelated to you. If not applicable, list three school or personal references who are not related to you.

Name / Telephone # / Years Known

Additional Information: List professional, trade, business, or civic associations and any offices held. YOU MAY EXCLUDE MEMBERSHIPS WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY OR ANY OTHER SIMILARLY PROTECTED STATUS.

Organization / Offices Held

List any special accomplishments, publications, awards, etc... YOU MAY EXCLUDE MEMBERSHIPS WHICH WOULD REVEAL SEX, RACE, RELIGION, NATIONAL ORIGIN, AGE, COLOR, DISABILITY OR ANY OTHER SIMILARLY PROTECTED STATUS.

______

List any additional information you would like us to consider.______

______

Please read and initial each paragraph below. If there is any part of this section you do not understand, please ask the interviewer for clarification before signing.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I understand that any omission or misstatement on this application or on any documents used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I give Grafton County the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability Grafton County and its representatives for seeking, gathering and using such information and, all other persons, corporations or organizations for furnishing such information.

Grafton County does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state or federal law.

If the position applied for requires driving in the course of work, I understand that I will be required to possess a current and valid driver’s license and understand that I will be required to provide a copy of my official driving record and proof of insurance. I also understand that any offer of employment is contingent on my ability to be covered by Grafton County’s auto insurance, if required for my position.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and Grafton County reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of Grafton County, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I understand it is Grafton County’s policy not to refuse to hire a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA.

I understand that if I am hired, as a condition of employment, I will be required to provide proof of identity and legal right to work in the United States on my first day of employment.

I represent that I have read and fully understand the foregoing and seek employment under these conditions.

Signature of Applicant: ______Date: ______

(Your signature is required.)

Submit application to:Grafton County Human Resources Dept.Phone:603-787-2034

3855 Dartmouth College Highway, Box 3Fax:603-787-2014

No. Haverhill, NH 03774

05/2017

Reference Checking Consent and Authorization Form

Disclosure

Please read the information on this form carefully and completely.

I have applied for employment with Grafton County and have provided information about my previous employment. I authorize Grafton County to conduct a reference check with my present and/or previous employer(s). I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary and employment history.

My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment to Grafton County, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Grafton County from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Grafton County.

This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.

Name: ______Signature: ______

(Please print)

Date: ______

Cell Phone: ______Alternate Phone: ______

Email Address: ______

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