Washakie County

Application Form

P.O. Box 260

Worland, WY 82401

(An Equal Opportunity Employer)

PERSONAL INFORMATION

Full Name _______________________________________________Social Security No. ______________

Street __________________________________________________ Phone Number (____) ____________

City-State-Zip Code_______________________________________________________________________

Message Phone:

Full Name ________________________________________City-State-Zip Code______________________

Phone Number (____) _________________________________

EDUCATIONAL BACKGROUND

Type of School	School Name City and State Where Located	Last Year completed (Circle)	Did You Graduate? (Circle)	Major Course of Study And Degree Granted
High School		1 2 3 4	Y N


College or Technical School		1 2 3 4	Y N


Post Graduate Courses		1 2 3 4	Y N

RELATED CAREER EDUCATION (Additional Courses, Trade Schools, Seminars, etc.)

Briefly describe courses, length of program and when completed:

__________________________________________________________________________

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

__________________________________________________________________________
PREVIOUS EMPLOYMENT (List most recent position first)

(Current or Most Recent Position)

Name of employer (company or firm)______________________________ Phone # (____)________________

Complete Address _________________________________________________________________________

Date hired ____________ Date terminated _______________Final Salary$_____________________________

(month and year) (month and year) Hourly * Bimonthly * Monthly * Yearly (circle One)

Position title ____________________________ Description of duties ________________________________

_________________________________________________________________________________________

Reason for leaving _________________________________________________________________________

(Previous Position)

Name of employer (company or firm) ______________________________Phone # (____)________________

Complete Address__________________________________________________________________________

Date hired ______________ Date Terminated _______________ Final Salary $ ________________________

(month and year) (month and year) Hourly * Bimonthly * Monthly * Yearly (circle one)

Position title ______________________________ Description of duties _______________________________

_________________________________________________________________________________________

Reason for leaving _________________________________________________________________________

(Previous Position)

Name of employer (company or firm) _____________________________Phone # (____)________________

Complete Address ________________________________________________________________________

Date hired ______________ Date Terminated _______________ Final Salary $ _______________________

(month and year) (month and year) Hourly * Bimonthly * Monthly * Yearly (circle one)

Position title __________________________ Description of duties ________________________________

_______________________________________________________________________________________

Reason for leaving _______________________________________________________________________

PLACEMENT INFORMATION

Type of position desired: ____________________________________________________________________

_________________________________________________________________________________________

Salary expected to start: $ ______________ per hour * month * year (circle one)

Earliest date available: __________________ Status desired: Full time * Part time * Either (circle one)

Related technical skills (list only skills or licenses pertinent to position applying for):

_________________________________________________________________________________________

EMPLOYMENT REFERENCES

List 3 previous supervisors or co-workers whom we can immediately contact:

1. Name _____________________________________ Phone # (_____) _____________________________

Former or current relationship to you ________________________________________________________

Current company name __________________________________ City, State ________________________

2. Name _____________________________________ Phone # (_____) _____________________________

Former or current relationship to you ________________________________________________________

Current company name __________________________________ City, State ________________________

3. Name _____________________________________ Phone # (_____) _____________________________

Former or current relationship to you ________________________________________________________

Current company name __________________________________ City, State ________________________

GENERAL INFORMATION

Please describe the skills and aptitudes that you feel qualify you for a position with us. (You may wish to include activities and positions held in civic, community and school organizations, professional societies, special training and skills.) Organizations that would reveal race, ethnic or any other protected status need not be listed.

____________________________________________________________________________________________

Have you ever been convicted of a crime? If yes, please explain. Include date, place and nature of crime. Convictions will not necessarily disqualify an applicant.) Yes £ No £

___________________________________________________________________________

__________________________________________________________________________________________

PLEASE READ CAREFULLY

The information provided on this application is accurate to the best of my knowledge and subject to verification. I understand that proof of U.S. permanent residency or authorization to work in the U.S. may be required upon employment. I understand that I must answer truthfully all the questions on this application. I also understand that if I do not, I may be refused employment or separated if I am a current employee.

If employment results from this application, I understand that additional personal data will be required to determine if I am eligible for benefits and for statistical/government reporting purposes.

I understand and acknowledge that prior to and/or during employment, I may be required to submit to medical testing for alcohol and/or illicit and/or controlled substances, and I hereby consent to such testing.

I authorize all previous employers and listed references to furnish whatever information they may have regarding my employment and my reason for leaving. And I release my prior employers from all liability for any damage resulting from the information provided.

I understand that employment with Washakie County is at will and either party with or without notice may end the employment relationship at any time.

___________________________________ ___________________________________________

Date Applicant’s Signature

APPLICANT Ö DO NOT WRITE BELOW THIS LINE

__________________________ __________________________

Interviewer Date

Comments: __________________________________________________________________________________

____________________________________________________________________________________________

Referred to Department Head: Y N

Interviewed for vacant position: ___________________________________________________________

Title and Position Description

Interviewing Department Head ________________________________

Salary/Wage $_________________________________ Start Date:_______________________

Hourly * Bimonthly * Monthly * Yearly (circle one)

Approved: ___________________________________ _______________________________

Personnel Officer Date

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