Employment Application for Agency Director
INSTRUCTIONS: Please fill out this application as completely and concisely as possible.
PRINT ALL RESPONSES EXCEPT YOUR SIGNATURE
DATE OF APPLICATION
POSITION SEEKING
WAGE DESIRED
ARE YOU WILLING & ABLE TO WORK WEEKENDS AND EVENINGS?
o Yes o No
DO YOU HAVE ANY RESTRICTIONS
ON WORKING OVERTIME?
o Yes o No
DATE AVAILABLE
NAME (Last) (First) (Middle)
ADDRESS (Street) (City) (State) (Zip)
HOME TELEPHONE
( ) -
CELL PHONE
( ) - / Are you able to perform the task for the position you are seeking with or without an
accommodation? o Yes o No
If no, how would you perform these tasks and with what accommodation?
Please attach a resume including work history of all permanent positions in chronological order beginning with the most recent position, your resume should be no longer that five pages. Please include:
· Employer, give complete names and addresses
· Start and end dates
· Job duties and responsibilities
· Reasons for leaving
· Include military service
· If self-employed, give firm name.
· If there are any gaps in employment please explain
Please list educational background in chronological order:
· All educational activities from high school through current date, include educational institution with start and end dates
· Degrees received
Certificates and Licenses.
Professional Associations
Please list three professional references with current contact information.
Complete attached supplemental questionnaire. Responses should be no longer than five pages.
Have you ever applied to or been employed by the State of Nebraska? o No o Yes If yes, when
How were you referred to us? Check one o Walk-In o Civic Organization o School o Newspaper o Agency o College Recruiting
o State Employment Office o Employee Referral o Other
Have you been convicted of a felony within the last 7 years? o No o Yes If yes, please explain
Do you wish to claim Veteran’s Preference? ______If so, you must submit a DD214 or NGB22 verifying dates of service and type of discharge. Include any documentation showing you receive or are eligible to receive benefits from the US Veterans Administration.
If employed do you have a valid driver’s license and/or the ability to provided independent transportation?______
We are an Equal Opportunity Employer. We do not discriminate in employment because of race, creed, color, religion, sex, national origin, age, disability, or veteran status. All information you supply will be kept in confidence and will not be used to discriminate against you in any unlawful manner. We voluntarily and enthusiastically comply with all of our Human Resource responsibilities including all applicable laws and regulations.
CERTIFICATION, AUTHORIZATION, RELEASE, AND WAIVER
READ CAREFULLY BEFORE SIGNING
I certify that the information given by me in this employment application and attached resume is true and complete and I understand and agree that my employment may be immediately discontinued if misrepresentations, falsified statements, or material omissions are found to be made. I authorize schools, former employers and former supervisors to provide any and all information pertinent to my employability and hereby release those providing such information from any liability for doing so. I also understand that employment, if offered, is contingent upon my providing additional information for employee record purposes.
I understand that I will have to produce documentation verifying identity and employment in the US on or before my hire date. I further understand that the State of Nebraska participates in the e-verify program and that any information provided will be validated through the Federal program.
I have read the above, understand its content and meaning and voluntarily and freely agree to all of its provisions.
SIGN HERE DATE
We participate in E-Verify®
E-Verify® is a registered trademark of the U.S. Department of Homeland Security.
Employment Application 12/14
Employment Application 12/14