Iowa State University Extension and Outreach Plymouth County

EMPLOYMENT APPLICATION

An Equal Opportunity/Affirmative Action Employer

Iowa State University and Outreach Plymouth County does not discriminate on the basis of race, color, age, religion, national origin, sexual orientation, sex, marital status, disability or status as a U.S. Vietnam Era Veteran. Any persons who have inquiries concerning this may contact the Director of Equal Opportunity and Diversity.

NOTE: Resumes are optional. If you would like a copy of your application for your records, please make a copy before submitting the original to our office.

1. Social Security Number / - / -
2. Full Name

LastFirstMiddle

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

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

4. Address

Street/P. O. Box/Apt #CityStateZip

5. Are you 18 years of age or older? / (Yes/No)
6. Are you legally authorized to work in the United States? / (Yes/No)

EDUCATIONAL DATA

High School Graduate or Equivalent (GED)? / (Yes/No)
Name and location of high school, college, vocational/technical schools / From / To
(Most Recent First) / Mo / Yr / Mo / Yr / Major or Course Title / Degree
a.
b.
c.
d.

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, briefly describe the major tasks performed.

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

- over-

1. EMPLOYMENT HISTORY (Current )

Employer / Type of Business
Employer's Address & Phone #
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:
List number and title(s) of employees supervised:
Duties: (Be Specific)

2 EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address & Phone #
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:
List number and title(s) of employees supervised:
Duties: (Be Specific)

3. EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address & Phone #
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:
List number and title(s) of employees supervised:
Duties: (Be Specific)

4. EMPLOYMENT HISTORY

Employer / Type of Business
Employer's Address & Phone #
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:
List number and title(s) of employees supervised:
Duties: (Be Specific)

Describe background and work experiences that would prepare you for this position:

COMMENTS: To be used to summarize any additional information that you feel may be appropriate.

CERTIFICATION & AUTHORIZATION

I, the applicant, authorize Iowa State University Extension and Outreach Plymouth County to use the information and statements contained in this application to determine my qualifications for employment. I authorize Iowa State University Extension and Outreach Plymouth County to make inquiries of my former employers regarding my previous duties, responsibilities, performance, compensation, and eligibility for rehire. In addition, I authorize Iowa State University Extension and Outreach Plymouth County to conduct additional reference checks that may include reference referrals from previous employers.

I understand that a comprehensive background check may be conducted to determine my eligibility for hire. This may include but is not limited to, verification of degrees, investigations of criminal and/or conviction records, driving records, and/or a drug screen test as required by U.S. Department of Transportation regulations or university policies.

I certify that all statements made in my application are true and accurate, and that I have not omitted any material information or provided false or misleading information. I understand that any material omission or misrepresentation will result in my disqualification from consideration for employment or, if discovered after I begin employment, will result in my termination.

If hired, I agree to abide by the policies of Iowa State University Extension and Outreach Plymouth County.

/ / /

Applicant’s Signature Date

Thank you for completing this form.

IOWA STATE UNIVERSITY AND OUTREACH PLYMOUTH COUNTY

IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

… 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.
Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Cathann A. Kress, director, Cooperative Extension Service, Iowa State University of Science and Technology, Ames, Iowa.