Step 1 of 4 25% Application for EmploymentRipley County is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status. This application for employment is good for 30 days only. Consideration for employment after 30 days requires a new application. Please complete each section EVEN if you are submitting a resume.Personal InformationName(Required) First Middle Last Address(Required) Street Address Apt/Suite City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Date Available(Required) MM slash DD slash YYYY Desired PayPay Type Hour Salary Position Applied For(Required)Select a PositionHealth School LiaisonHealth EHS Inspector911 DispatcherHealth Clerical Nursing AssistantParks & Recreation CaretakerEMTFuture ConsiderationEmployment Desired(Required) Full-Time Part-Time Seasonal Employment EligibilityAre you legally eligible to work in the U.S.?(Required) Yes No Are you over 18 years old?(Required) Yes No Have you ever worked for this employer?(Required) Yes No If yes, fill the start, end dates, and departmentStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY DepartmentHave you ever been convicted of a felony?(Required) Yes No If yes, please explainRecord of Conviction(A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered).Have you ever been convicted of, pled guilty to, or entered into a pre-trial agreement or similar program with repect to a felony or misdemeanor other than a minor traffic offense?(Required) Yes No If yes, please explain EducationHigh School(s)City/StateFromToDiploma Yes No G.E.D. Yes No College and/or Vocational School(s)City/StateFromToGraduate? Yes No MajorDegrees/Certificate EarnedOther Training or DegreesSchoolCity/StateFromToDegree/Cert Earned Add RemoveProfessional License or Membership(You need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status.)Type of License(s) HeldState of Indiana License NumberLicense Expiration DateOther Professional Memberships Previous EmploymentList last employer first, including U.S. Military Service.May we contact your present employer Yes No If any employment was under a different name, indicate nameEmployer(s)EmployerE-MailPhoneAddressSupervisorDepartmentJob TitleResponsibilitiesFrom (Month/Year)To (Month/Year)SalaryReason for Leaving Add Remove ReferencesProfessional OnlyReferences ListNameRelationshipCompanyTitleE-MailPhone Add RemoveBackground Check ConsentIf asked, are you willing to consent to a background check?(Required) Yes No Upload Resume or CVHave a resume or cv that you’d like to include? Please upload it here.Resume or CVAccepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 122 MB.Applicant's Certification and AgreementI hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Ripley County to verify their accuracy and to obtain reference information on my work performance. I hereby release Ripley County from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient bases for dismissal. I understand that Indiana law prohibits smoking throughout the County’s facilities by employees, Department Heads, and Elected Officials. I further understand that I may be subject to penalties under Indiana law and also subject to disciplinary action up to and including termination of employment if I violate this policy. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. However, I further understand that neither the policies, rules, regulations of employment nor anything said during the interview shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause.Signature(Required)Verification of Application for Employment for Compliance with the Ripley County Nepotism Policy(Required) I hereby verify under the penalty of perjury that the foregoing statements are true.I have reviewed the direct line of supervision for the position I am seeking with Ripley County and I am not a relative of any employee who will be in my direct line of supervision in the position for which I’m applying for. I understand that Relative means my spouse, parent or stepparent, child or stepchild, brother, sister, stepbrother, stepsister, niece, nephew, aunt, uncle, daughter-in-law or son-in-law (including half-bloods and adopted children).Signature(Required) 46402
