M A Driver's License

Position Applying For

Date of Application

The following information is requested in order to help us make the best possible placement with Grant County. All portions of this application pertaining to you must be completed. Grant County does not discriminate on the basis of age, race, religion, color, sex, national origin, marital status, disability, sexual orientation or any other characteristic protected by law.

PERSONAL DATA:

Name

Last

First

Initial

Home phone Address

Other phone Street/PO Box

Email address

City

State

Zip Code

Are you 18 years or older? Yes No

Are you legally eligible for employment in the United States? Yes No

Do you have a valid Driver's License? Yes No

Do you have a CDL (if required)? Yes No

Have you ever been convicted of a crime other than minor traffic violations? Yes No

(A criminal record will be considered only as it relates to the job applied for.)

If yes, please explain:

Are you related to any employee of Grant County? Yes No

If yes, please list his/her name and your relationship.

Have you worked for a WRS (Wisconsin Retirement System) participant in the past? Yes No

EDUCATION AND TRAINING:

School

Name and Location

(Optional)

Dates Attended

From: To:

Course of Study

and Degree

Graduated

High School/GED

Yes No

College or University

MO YR MO YR

Yes No

Graduate School

MO YR MO YR

Yes No

Business, Trade, Vocational or Other

MO YR MO YR

Yes No

List Additional Skills Acquired:

EMPLOYMENT RECORD:

Please complete by beginning with last or current employer, then next to last, etc.

If currently employed, may we contact that employer? Yes No

Employer

Phone

Dates of Employment

From To

Address

Salary (Optional)

Hours/Week

Supervisor

Reason for Leaving

Job Title

Description/Duties

Employer

Phone

Dates of Employment

From To

Address

Salary (Optional)

Hours/Week

Supervisor

Reason for Leaving

Job Title

Description/Duties

Employer

Phone

Dates of Employment

From To

Address

Salary (Optional)

Hours/Week

Supervisor

Reason for Leaving

Job Title

Description/Duties

Employer

Phone

Dates of Employment

From To

Address

Salary (Optional)

Hours/Week

Supervisor

Reason for Leaving

Job Title

Description/Duties

(Use a separate sheet for additional employers.)

MILITARY SERVICE RECORD:

Have you ever been in the armed forces?

Yes No

If yes, what branch?

Dates of duty:

From

To

Rank at Discharge:

What were your duties in the service (include special training and duty station)?

REFERENCES:

List persons who are familiar with your qualifications and background. (No relatives)

Name

Address/Phone

Business or Occupation

1.

2.

3.

SUMMARY

Please summarize any special skills or qualification you have acquired that will support your application for this position.

PLEASE READ THE PARAGRAPHS BELOW BEFORE SIGNING:

GRANT COUNTY RELEASE OF INFORMATION,

WAIVER OF LIABILITY, RELEASE OF CLAIMS, AND

INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

Authorization. I,, want and authorize Grant County (the “County”) to conduct a thorough and detailed investigation of my personal history, including my employment history and education history, and including the employers, businesses, schools, entities, and any persons named in my application, in any other documents filed with the County during the hiring process, or as otherwise learned of or contacted by the County, to give any information, including records, regarding my education, employment, character, and qualifications.

I want and authorize any person contacted to provide the County any information regarding my employment, education, and other information about me, which may include, but not be limited to, information about my employment, performance, character, evaluations, work records (excluding workers compensation information and medical information, if any, but including medical files relating to mental competency issues bearing on my suitability for a law enforcement officer position), wage rates, supervisors’ comments, results of any non-medical tests, discipline, employment counseling, investigations, and any reports or letters, and complaints or allegations regarding any misconduct.

I agree to execute release authorization forms as required by the County or my current or former employers to request employment records from my present and/or former employer(s).

I authorize the County to conduct a background criminal history check. I recognize that information received about my arrest and conviction record will be considered by the County only if it substantially relates to the employment position.

I understand this authorization is not an authorization for the County to conduct a credit history check under the Fair Credit Reporting Act. I understand the County will provide me with a separate conspicuous notice informing me of the County’s decision to perform a credit history check, and notice of my rights and ability to authorize and grant permission for the credit history check under the Fair Credit Reporting Act.

Waiver. I waive all rights to privilege or confidentiality that may exist with respect to the release of the above-referenced records and information. I waive my right of access to the records and information received by the County.

Release, Hold Harmless, and Indemnification. I release, hold harmless and agree to indemnify the County, which includes all of its employees, officers, agents, attorneys, representatives, insurers, and investigators utilized by the County, and any employers, businesses, schools, entities and any other persons (collectively, the “Other Parties”) who provide information and records about me, from or for any liability, claims, judgments or damages related to providing any information or records about me and including the information provided about me. I will indemnify and defend the County and the Other Parties from and against any and all claims, demands, actions and damages, including payment of their attorneys’ fees and costs, of whatever nature made or asserted by me or any person acting or claiming to act on my behalf against the County or the Other Parties related to or involving the release or use of these records and information about me, regardless of the outcome of the proceedings.

I fully understand my obligations under Wis. Stat. § 165.85(4)(em)1 to release the interviewing agency and each law enforcement agency, tribal law enforcement agency, jail, juvenile detention facility, or government agency that employs or has employed me from any liability related to the use and disclosure of my employment files and records, and I intend through this authorization to release those parties from liability and any other person providing information about me pursuant to this authorization.

Understanding and Agreement. With knowledge of the circumstances and the rights that I give up, I freely sign this binding Agreement and waive the rights I might otherwise have to bring any claim against the County and these Other Parties and with full knowledge of my responsibility of indemnification of the County and these Other Parties and my release of any claims against them. I understand the County may no longer consider my application for employment if I did not agree to the terms of this Agreement. I understand that information provided to the County by the Other Parties may result in me not being employed by the County. I recognize the responsibility the County has to others through the County’s hiring practices, and I recognize the County’s costs of operations may be substantially higher if I did not agree to these terms. I waive my right to negotiate for different terms.

If for any reason a court of competent jurisdiction finds any provision of this Agreement to be illegal or unenforceable, I want the offending provision to be deemed amended to the extent necessary to conform to the applicable law and for the fullest protection of the interests of the County and Other Parties.

I understand my personal information about me, including my gender, my birthdate, my social security number, and driver’s license number, are requested by the County for purposes of verifying my identity, to avoid mistaken identity and for purposes of conducting an effective and thorough background examination. I understand the County will not consider my age or any other protected status information for purposes of hiring decisions.

The following information about me is true and correct to the best of my knowledge.

Names used: Birthdate:

Driver License Number:

Current Address:

Signature: Date:

Received by the Employer: Date:

Submit completed application to:

Grant County Personnel Department

111 S. Jefferson St.

PO Box 529

Lancaster, WI 53813

Email: **********@**.*****.**.***

Fax: 608-***-****; Phone: 608-***-****

If submitting your application materials via US Mail, please make sure you have enough postage as to not cause delay in processing.

How did you hear about this employment opportunity?

Facebook (www.facebook.com/GrantCountyEmploymentOpportunities)

Shopping News

Other Newspaper:

Grant County Website (www.co.grant.wi.gov www.co.grant.wi.gov/docs_by_cat_type.asp?doccatid=111&locid=147 )

Orchard Manor Website (www.omanor.com)

Job Center of Wisconsin Website (www.jobcenterofwisconsin.com)

School

Posting or email at my place of employment

Friend / Relative

Other:

Grant County

Drug and Alcohol Background Check

Complete only if applying for CDL required positions.

CDL Applicant Acknowledgement of Pre-Employment Drug Testing (49 CFR Part 655.17)

I understand that as part of my application for employment with Grant County, I must successfully complete a U.S. Department of Transportation (USDOT) drug test as required by 49 CFR Part 655.41. I further understand that a verified negative drug test result must be obtained by the employer, prior to performance of any safety-sensitive function, as defined by 49 CFR Part 655.4.

Applicant Name (Print):

Applicant Signature:

Date: / /

Questions for CDL Applicants (49 CFR Part 40.25 and 40.311)

1.Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by USDOT agency drug and alcohol testing rules during the past two years? Yes No

2.If yes, have you been evaluated by a Substance Abuse Professional (SAP) as required by 49 CFR Part 40, Subpart O (40.285)? Yes No

(Note: If yes, a written report from the SAP is required.)

3.If yes, did you complete USDOT’s Return-to-Duty process, including follow-up testing, as required by 49 CFR Part 40, Subpart O)? Yes No

(Note: If yes, a written report from the SAP is required.)

Grant County Application for Employment

THIS FACILITY MAY DO

DRUG TESTING

Contact this candidate