Employment Application

Position Applied For *

Salary Desired *

Personal Information

First Name *

Middle Name *

Last Name *

Phone *

Email

Address *

City *

State *

ZIP *

Education

What is the highest level of education have you completed? * Middle School
High School
College/University

If college, what is your degree?

Specialized training, skills, or abilities

Languages other than English you can speak, read, and/or write

Employment History

Are you currently employed? * Yes
No

Current Employer (or most recent employer)

Employer Name *

Type of Business *

Employer Phone *

Address *

City *

State *

ZIP*

Date of Employment (Start date/end date) *

(mm/yyyy)
(mm/yyyy)

Title of Your Position *

Name & Title of Your Immediate Supervisor *

May we contact this employer? * Yes
No

Description of duties, responsibilities and equipment operated *

Liked Most About Job *

Liked Least About Job *

Reason for Leaving *

Final Pay

$ Per

Previous Employer 1

Employer Name

Type of Business

Employer Phone

Address

City

State

ZIP

Date of Employment (Start date/end date)

(mm/yyyy)
(mm/yyyy)

Title of Your Position

Name & Title of Your Immediate Supervisor

May we contact this employer? Yes
No

Description of duties, responsibilities and equipment operated

Liked Most About Job

Liked Least About Job

Reason for Leaving

Final Pay

$ Per

Previous Employer 2

Employer Name

Type of Business

Employer Phone

Address

City

State

ZIP

Date of Employment (Start date/end date)

(mm/yyyy)
(mm/yyyy)

Title of Your Position

Name & Title of Your Immediate Supervisor

May we contact this employer? Yes
No

Description of duties, responsibilities and equipment operated

Liked Most About Job

Liked Least About Job

Reason for Leaving

Final Pay

$ Per

Previous Employer 3

Employer Name

Type of Business

Employer Phone

Address

City

State

ZIP

Date of Employment (Start date/end date)

(mm/yyyy)
(mm/yyyy)

Title of Your Position

Name & Title of Your Immediate Supervisor

May we contact this employer? Yes
No

Description of duties, responsibilities and equipment operated

Liked Most About Job

Liked Least About Job

Reason for Leaving

Final Pay

$ Per

Employment Information

Are you legally eligible to work in the U.S.A? * Yes
No

On what date would you be available to work? * (mm/dd/yyyy)

Hours/week desired

What hours are you available to work?

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Do any of your relatives work for this company?

YesNo
If yes, who?
Relationship

Have you previously worked for Benton County? YesNo

Have you been convicted of a felony?

YesNo
If yes, please explain where, when, and disposition of case:
(Conviction will not necessarily disqualify an applicant from employment.)

Have you served in the U.S. Armed Forces or National Guard?

YesNo
Describe your experience

Do you have a valid driver's license? YesNo

If yes, state issued

License Number

Any dates of driver's license suspensions

Professional References

Reference 1

Name *

Title *

Phone Number *

Describe Your Relationship to this Reference *

Reference 2

Name *

Title *

Phone Number *

Describe Your Relationship to this Reference *

Reference 3

Name *

Title *

Phone Number *

Describe Your Relationship to this Reference *

Optional Resumé Upload

Upload Resumé and optional Cover Letter

(Please submit a single PDF or Microsoft Word file)

Affirmative Action Survey (Optional)

Benton County is an equal opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability or any other basis protected by federal, state or local law. No question on this form is intended to secure information to be used for such discrimination.

Benton County is required by federal regulations to report information as requested below. You submission of this information is completely voluntary and in no way affects the decision regarding your employment opportunity. The information you provide is strictly confidential and will be maintained separately from your application form

Gender Identification MaleFemale

Minority Status Identification Hispanic or Latino
White
Black
Native Hawaiian or other Pacific Islander
Asian
American Indian or Alaska Native
Two or More Races

How did you learn of this job opening? *

Walk-In
Advertisement - Newspaper
Advertisement - Internet
Job Service of Iowa
Other Government Agency
School/College
Employment Agency
Search Firm
Employee Referral (provide name of employee)
Other (specify)

Applicant's Statement

I have reviewed the job description for this position and (check one): *

I am able to meet all of the job requirements for this position.
I am able to meet all of the job requirements for this position, except as follows:

By checking this box and submitting this electronic application, I affirm that I have read and I agree to the conditions of the application above, and that all information I have provided in this application is correct and complete to the best of my knowledge. I also affirm I am a U.S. citizen or Naturalized Citizen.

Do you agree?* Yes, I agree.

Administration, Business & Finance

Community Services

Government Services

Environmental Health & Land Use

Roads

Public Safety & Legal

Real Estate

Personal Information

Education

Employment History

Employment Information

Professional References

Optional Resumé Upload

Affirmative Action Survey (Optional)

Applicant's Statement