Application For Employment County of Jay, Indiana an Equal Opportunity Employer The County of Jay, Indiana, does not discriminate on the basis of race, color, gender, national origin, age, religion, or disability, in employment or the provision of services. Please type or print responses to ALL questions on the application form. Any application not completed in its entirety will be disqualified.Position Sought *Select Desired PositionCorrections OfficerCorrections Transport Officer911 DispatcherMerit DeputyKitchen CookOtherLast Name *First Name *Middle InitialFormer Name(s)Street Address *City/State/Zip *Phone *Are you at least 18 years of age? *YesNoAre you at least 21 years of age? *YesNoAre you related to an employee currently employed by the County? *YesNoIf yes, please state relationshipand current departmentAre You interested in:Full-time work? *YesNoPart-time work? *YesNoTemporary work? *YesNoDate available to start workList all employment history and work experience during the previous five years, beginning with your current employer. Failure to include all past employment may be grounds for disqualification. If currently unemployed, check here and skip to Previous employer belowUnemployedCurrent EmployerStreet AddressCity/State/ZipPhoneHire DateJob TitleBeginning SalaryPerCurrent SalaryPerSupervisorTitleWork PhoneJob DutiesWhy do you want to leave?May we contact your current employer?YesNoIf no, please explain why---------------------------------------------------------------------------------------------------Previous EmployerPhoneStreet AddressCity/State/ZipHire DateEnd DateJob TitleBeginning SalaryPerEnding SalaryPerSupervisorTitleWork PhoneJob DutiesWhy did you leave?May we contact your current employer?YesNoIf no, please explain why---------------------------------------------------------------------------------------------------Previous EmployerPhoneStreet AddressCity/State/ZipHire DateEnd DateJob TitleBeginning SalaryPerEnding SalaryPerSupervisorTitleWork PhoneJob DutiesWhy did you leave?May we contact your current employer?YesNoIf no, please explain why---------------------------------------------------------------------------------------------------Previous EmployerPhoneStreet AddressCity/State/ZipHire DateEnd DateJob TitleBeginning SalaryPerEnding SalaryPerSupervisorTitleWork PhoneJob DutiesWhy did you leave?May we contact your current employer?YesNoIf no, please explain why--------------------------------------------------------------------------------------------------- List and explain periods of unemployment in the past five yearsFromToReason For UnemploymentFromToReason For UnemploymentThis section is intended to give the employer information about education and training you have completed, and to describe your skills, knowledge and abilities to perform the duties of the position.EducationHigh School NameStreet AddressCity/State/ZipDiploma? *YesNoGED? *YesNoActivities & Awards---------------------------------------------------------------------------------------------------College Or Trade School NameFromToStreet AddressCity/State/ZipDegree(s)Major/Minor Courses Of Study---------------------------------------------------------------------------------------------------College Or Trade School NameFromToStreet AddressCity/State/ZipDegree(s)Major/Minor Courses Of Study---------------------------------------------------------------------------------------------------Activities & AwardsSeminars, Workshops, Awards--------------------------------------------------------------------------------------------------- Military History & StatusIf you have never served in the military on active duty, check the box below and skip to the next sectionI Have Served Active DutyMilitary BranchDate Of ServiceHighest Rank AttainedRank at SeparationMilitary BranchDate Of ServiceHighest Rank AttainedRank at SeparationType of DischargeCitations/awards received--------------------------------------------------------------------------------------------------- Professional or Specialized TrainingSpecialized TrainingProfessional/special license(s) or certificate(s):StateIssued ByDate IssuedExpirationTypeLicense #---------------------------------------------------------------------------------------------------StateIssued ByDate IssuedExpirationTypeLicense #Have you had any license suspended, revoked or terminated?YesNoIf yes, please explain why--------------------------------------------------------------------------------------------------- Professional AffiliationsList current or previous affiliations/organizations and related offices/positions.Organization NameAddressPhoneOffices/PositionsOrganization NameAddressPhoneOffices/Positions---------------------------------------------------------------------------------------------------Use the following space to describe other training, education, skills, abilities, hobbies, volunteer work, or other information that may be helpful in evaluating your application.Do you have any commitments which might interfere with or adversely effect your employment with us, such as a second job or school?YesNoIf yes, please explain whyHave you ever been convicted of a felony?YesNoIf yes, please explain why---------------------------------------------------------------------------------------------------List three references who are not related to you and are not former employers or supervisors:NamePhoneStreet AddressCity/State/ZipNumber of years known---------------------------------------------------------------------------------------------------NamePhoneStreet AddressCity/State/ZipNumber of years known---------------------------------------------------------------------------------------------------NamePhoneStreet AddressCity/State/ZipNumber of years knownAre you currently required to register as a sex offender in this or any other jurisdiction?YesNoIf yes, please explain (including jurisdiction of registry)Read each of the following paragraphs carefully. Indicate your understanding of, and consent to, the contents and conditions of each paragraph by signing your initials at the end of each paragraph. If you have any questions regarding these paragraphs, contact the employer before initialing.Initials *0 / 2I understand and accept that, if I am hired, I may be hired conditional on passing any medical and/or psychological examinations that the employer deems necessary to determine my ability to perform the essential functions of the position. I understand and accept that this may include drug, alcohol, or substance abuse testing.Initials *0 / 2I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further considersation. I further understand and accept that, if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded.Initials *0 / 2I solemnly swear that all of the information furnished in this employment application is true, accurate, and complete to the best of my knowledge. I authorize investigation of all statements contained in this application. I understand that my misrepresentations or falsification of the information provided may lead to withdrawal of an employment offer or termination following employment.Initials *0 / 2I understand that the employer provides sheriff service on a seven day per week and twenty-four hour per day service, and therefore, if employed by the Sheriff's department, I may be required to work evening shifts or night shifts, including weekends and holidays.Initials *0 / 2(Deputy Only) I understand that if I am hired as a sworn officer on the Sheriff's department, that I must successfully complete required training and courses specified and be certified by the State of Indiana Police Academy.Initials0 / 2By submitting this document, I hereby agree that I shall execute the employer's conditional and post-employment medical examination and drug testing consent requirements. I recognize that my future employment with the employer will be jeopardized if I engage in substance abuse, illegal drugs use, or alcohol abuse.Application Signature *Submit Application