Employment Application

Contact Information

1. Position you are applying for: Choose an open position.
2. Date of Application
3. How did you learn about us? Please Select Advertisement Indeed Job Fair Website Referral from Other
If Referral from, please list here:
If Other, please list here:

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4. Last Name
5. First Name
6. Middle Name
7. Address
8. City
9. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
10. Zip
11. Phone
12. Email
13. Please share briefly why you are interested in employment with Benton County.

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14. Best time to contact you is Please Select AM PM AM/PM
15. Preferred method of contact (i.e. specific phone number or email)
16. If you are under 18 years of age, can you provide required proof of your eligibility to work? Please Select Yes No I am not under 18 years of age
17. Have you ever filed an application with Benton County before? Please Select Yes No
If yes, give date and position applied for:
18. Have you ever been employed by Benton County before? Please Select Yes No
If yes, give date and position held:
19. Do any of your relatives or friends work for Benton County? Please Select Yes No
If yes, provide name and position or department for each such person:
20. Are you currently employed? Please Select Yes No
Can we contact current employer? Please Select Yes No
21. Are you authorized to work in the U.S.? Please Select Yes No
22. Will you now or in the future require sponsorship for employment status (i.e., H-1B visa status, etc.)? Please Select Yes No
23. Have you ever been discharged or asked to resign from employment? Please Select Yes No
IF YOU HAVE ANSWERED "YES" TO THE ABOVE QUESTION, PLEASE EXPLAIN BELOW. A "YES" ANSWER DOES NOT AUTOMATICALLY DISQUALIFY YOU FROM CONSIDERATION OF YOUR APPLICATION OR FROM EMPLOYMENT.
24. Date available for work
25. What is you desired salary range?
26. Are you available to work:
    Check all that apply
    Full-Time
    Part-Time
    Temporary
    
27. Please indicate dates available:
28. to
29. Are you currently on "lay-off" status and subject to recall? Please Select Yes No
30. Can you travel if a job requires it? Please Select Yes No

Veterans Preference

Chapter 35C of the Code of Iowa provides certain rights, including preference in hiring if equally qualified to other applicants, to certain veterans of United States Military Service. Qualification for these rights is defined in this statute.

31. Are you a veteran of United State Military Service? Please Select Yes No
Branch of Service and dates of Active Duty
32. Are you a member of the Reserves or National Guard? Please Select Yes No
Any person who may wish to claim a Veterans Preference must submit a copy of a certified form DD214 by the deadline set for the receipt of applications for the position for which the person is applying.

Qualifications

33. Can you perform the requirement of this job with or without reasonable accommodations? Please Select Yes No

Education

34. High school graduate or equivalent (GED)? Please Select Yes No

Location 1

35. Name and Location of Schools Attended or Vocational Training Obatained Beyond High School
36. Degree/Certficiation

Location 2

37. Name and Location of Schools Attended or Vocational Training Obatained Beyond High School
38. Degree/Certficiation

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities.

Employer 1

39. Employer Name
40. Job Title
41. Address
42. City
43. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
44. Zip
45. Phone
46. Start Date
47. End Date
48. Starting/Ending Pay
49. Supervisor Name
50. Work Performed
51. Reason For Leaving
52. May we contact this employer? Please Select Yes No
Add Employer

Employer 2

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Starting/Ending Pay

Supervisor Name

Work Performed

Reason For Leaving

May we contact this employer? Please Select Yes No

Add Employer

Employer 3

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Starting/Ending Pay

Supervisor

Work Performed

Reason For Leaving

May we contact this employer? Please Select Yes No

References

Reference 1

53. Name
54. Relationship
55. Phone
56. Email

Reference 2

57. Name
58. Relationship
59. Phone
60. Email

Reference 3

61. Name
62. Relationship
63. Phone
64. Email

Additional Information

Other qualifications or specialized skills

65. Summarize special job-related skills and qualifications acquired from employment or other experience.
66. If the job description asked for any preferences (such as location) or if you'd like to provide other comments, please do so below.
67. Have you ever been convicted of a felony?
    For purposes of these questions, convicted includes plead guilty, plead no contest, or been given a deferred sentence of judgment. Please Select Yes No
If yes, please explain.
Note: A conviction will not automatically disqualify an applicant for a particular job and that the type and seriousness of the crime, the frequency of violoations, the date of conviction, and the applicant's entire work and educational history will be considered.

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigations of all statments contained in this Application for Employment as may be necessary in arriving at an employment decision. In connection with my application with the County, I expressly authorize the release to the County of any records or information which may refer or relate to my application for employment, including, but not limited to, records of schools, law enforcement or criminal justice agencies, social media accounts and previous employers. I hereby release and discharge the County and any other person, firm, agency or corporation from any and all claims and liability which I may have or ever claim to have relating to information provided to the county as part of my application for employment.

I authorize Benton County to conduct a check of the status of my driver's license and my driving record.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Benton County is "at will," which means that the Employee may resign at any time, and the Employer may discharge the Employee at any time with or without cause. It is further understood that the "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of Benton County.

I understand that any offer of employment that is extended to me is considered to be a conditional offer and is subject to successful completion of all required background checks. Identifying information such as my social security number and driver's license number will be requested at the post-offer, pre-employement stage, unless identifying information must be requested earlier in the hiring process for positions such as law enforcement positions.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I will be required to abide by all rules and regulations of the Employer.


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68. I agree to give Benton County permission to complete appropriate background checks. Please Select Yes No

Signature of Applicant

69. Signature Please type your full name to serve as an electronic signature.
70. Today's Date

Benton County is an equal opportunity employer.




Benton County Authorization for Release of Personal Information

I do hereby authorize a review of, and full disclosure of, all records concerning myself to a duly authorized agent of Benton County, Iowa or the Benton County Sheriff's Office, whether the said records are of a public, private or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of records of educational institutions, financial or credit institutions, including records of loans, records of commercial or retail credit agencies (including credit reports and/or ratings) and other financial statements of records whenever filed; medical and psychiatric treatment and/or consultation, including hospitals, clinics, private practitioners, and U.S. Veterans Administration; employement and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me; and the recollections of attorneys at law, or of other counsel whether representing me or another person in any case, either criminal, or civil, in which I have personally have, or have had an interest.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon which this release authorization will be considered in determining my suitability for employment by Benton County, Iowa and the Benton County Sheriff's Office. I also certify that any person(s) who may furnish such information in good faith concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release Benton County, Iowa and the Benton County Sheriff's Office from any and all liability which may be incurred as a result of collection of such information.

I HEREBY SWEAR AND AFFIRM THAT EACH STATEMENT AND ALL INFORMATION IN OR SUPPLEMENTING THIS APPLICATION ARE COMPLETE, TRUE AND ACCURATELY RECORDED TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT PROVIDING FALSE, MISLEADING AND/OR INCOMPLETE INFORMATION ON THIS APPLICATION IS GROUNDS FOR EXCLUSION FROM THE SELECTION PROCESS OR DISCHARGE IF DISCOVERED SUBSEQUENT TO EMPLOYMENT.

A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature.

I have read and fully understand the contents of the "Authorization of Personal Information."

71. Signature of Applicant Please type your full name to serve as an electronic signature.
72. Today's Date