Applicant Information
Today’s Date
Department
Position Applying For
First Name
Middle Name
Last Name
Suffix
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
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
United States Minor Outlying Islands
Virgin Islands
Zip Code
Home Phone
Cell/Alternate Phone
Email Address
General Questions
If you have been employed with Washington County:
Date(s)
Department
Give a brief statement in your own words on why you would like to work for Washington County
Driving Record
Drivers License Number
License Class
Endorsements
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
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
United States Minor Outlying Islands
Virgin Islands
Exp. Date
If yes, how many points?
Education & Training
If not, what is the highest grade completed?
Name, City, State of Last High School Attended
If you have a GED:
Year Awarded
State Awarded
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
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
United States Minor Outlying Islands
Virgin Islands
Colleges Attended
School
Major
Degree
Starting
Ending
Other Training (including business, trade, military, etc.)
Source
Location
Type
Hours
Weeks
Special Qualifications (apprenticeships, skills, academic, or professional awards, etc.)
Other Qualification Details
General Information
INSTRUCTIONS: The information listed below must be completed by all applicants. Failure to complete this information truthfully may result in disqualification from consideration for County employment. Affirmative responses to these questions will not automatically exclude you from employment consideration. Applicants may attach additional sheets if necessary:
Please describe the facts and circumstances:
If yes, please explain.
Employment & Training
Name of Employer
Employer Address
Type of Business
Supervisor’s Name and Phone Number
Job Title
Job Titles of Those You Supervised
Dates of Employment
Starting Salary
Ending Salary
Job Duties
Reason for Leaving
Name of Employer
Employer Address
Type of Business
Supervisor’s Name and Phone Number
Job Title
Job Titles of Those You Supervised
Dates of Employment
Starting Salary
Ending Salary
Job Duties
Reason for Leaving
Name of Employer
Employer Address
Type of Business
Supervisor’s Name and Phone Number
Job Title
Job Titles of Those You Supervised
Dates of Employment
Starting Salary
Ending Salary
Job Duties
Reason for Leaving
Employment References
Each applicant is required to provide 3 references
Name
Address
Phone
Relationship
Pre Employment Statement
PRE-EMPLOYMENT STATEMENT
READ CAREFULLY BEFORE SUBMITTING FORM
I certify that, if employed, I will produce documents to establish that I am legally able to work in the United States. I understand that a final employment offer is contingent upon completion of INS Form I-9 and receipt of acceptable documentation at the time of hire.
In the event that I am provided a conditional offer of employment, I consent to taking an employment physical examination to include an alcohol and drug screen and such future physical examinations as may be lawfully required by the County. I authorize the County to contact my previous employers, if necessary, and obtain employment information from them, and to further investigate the truthfulness of my application, including review of my motor vehicle record and such future periodic review as may be lawfully required by the County.
I certify that answers given herein are true to the best of my knowledge.
I understand further that any false answers or statements or misleading omissions made by me on this application, in any interview for employment, in connection with the above mentioned investigation, or in any physical examination shall be sufficient grounds for my rejection as a candidate for employment or for immediate discharge, if discovered after my hiring.
I AGREE THAT EMPLOYMENT WITH WASHINGTON COUNTY IS AN “AT-WILL” EMPLOYMENT RELATIONSHIP. AT-WILL EMPLOYMENT MEANS THAT EITHER THE EMPLOYER OR THE EMPLOYEE MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME FOR ANY REASON, WITH OR WITHOUT NOTICE, AND WITH OR WITHOUT CAUSE. I ALSO AGREE THAT NO REPRESENTATION BY ANY COUNTY OFFICIAL OR SUPERVISOR AND THAT NO PROVISION OF THE EMPLOYEE HANDBOOK, ANY PERSONNEL REGULATION OR ANY OTHER EMPLOYMENT RELATED PRACTICE OR PROCEDURE, ORAL OR WRITTEN, SHALL BE EFFECTIVE TO CHANGE THE “AT-WILL” NATURE OF EMPLOYMENT WITH WASHINGTON COUNTY.
“UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE-DETECTOR OR SIMILAR TEST. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100.”
Name of Applicant
Type Your Name Again to Sign
Affirmative Action & Race Information
APPLICANT DATA RECORD
Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, age, genetic or veteran status, sexual orientation, or disability.
As an employer, we comply with all government regulations and any applicable affirmative action responsibilities.
Solely to help us comply with any applicable government record keeping, reporting and other legal requirements, please fill out the Affirmative Action Survey below. We appreciate your cooperation.
This Affirmative Action Survey data, which you provide voluntarily, will be kept separate and confidential from this Application for Employment.
AFFIRMATIVE ACTION
Government agencies require periodic reports on the sex, ethnicity, disability, and veteran status of applicants. This data is for analysis and affirmative action only.
Birthdate
RACE/ETHNIC IDENTIFICATION (Please check all that apply)
Veteran Identification
Special Employment Notice to Disabled Veterans, Vietnam Era Veterans, and Individuals with Physical or Mental Handicaps
Government contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified handicapped individuals.
If you are a disabled veteran, or have a physical or mental handicap, you are invited to volunteer this information. This information will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment.
Veteran Identify Signature (type your name)
FMCSA
FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse
I hereby provide consent to Washington County Board of Commissioners to conduct a full query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse ( Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse.
I understand that if the full query conducted by Washington County Board of Commissioners indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Washington County Board of Commissioners without first obtaining additional specific consent from me.
I understand that Washington County Board of Commissioners will conduct annual limited queries as required by FMCSA.
I further understand that if I refuse to provide consent for Washington County Board of Commissioners to conduct a limited query of the Clearinghouse, Washington County Board of Commissioners must prohibit me from performing safety- sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’ s drug and alcohol program regulations.
Employee Signature (type your name)
File Uploads
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Cover Letter
Resume
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