Applicant Information

Date*

Last*

First*

Street Address*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code*

Phone*

Email*

Date Available*

Desired Salary

Position Applied for*

Yes

No

Are you eligible to work in the United States?

Full Time

Part Time

Employment Desired?

Yes

No

Have you ever worked for this organization?

Hours of work (per week) desired?*

Yes

No

Are you at least 18 years old? )If under 18, hire is subject to verification that you are of minimum legal age.)

Yes

No

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

If no, describe the functions that cannot be performed.
(Note: We comply with the ADA and consider reasonable accommodations measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Education

High School *

Address*

Did you graduate?

Yes

No

Number of years completed.*

University/College

Address

Did you graduate?

Yes

No

Number of years completed.

Degree

Other

Address

Did you graduate?

Yes

No

Number of years completed.

Degree

Employment History

List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.

Most Recent

Name of Employer*

Phone Number*

Type of Business *

Supervisor's Name*

Street Address*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code*

Date Began Employment*

Date Ended Employment

Pay

Hourly Rate

Annual Salary

Starting Pay*

Ending Pay*

Your Position and Duties*

Reason for Leaving*

Yes

No

May we contact this employer for a reference?

Second Most Recent Employer

Name of Employer

Phone Number

Type of Business

Supervisor's Name

Street Address

City

State

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code

Date Began Employment

Date Ended Employment

Pay

Hourly Rate

Annual Salary

Starting Pay

Ending Pay

Your Position and Duties

Reason for Leaving

Yes

No

May we contact this employer for a reference?

Third Most Recent Employer

Name of Employer

Phone Number

Type of Business

Supervisor's Name

Street Address

City

State

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code

Date Began Employment

Date Ended Employment

Pay

Hourly Rate

Annual Salary

Starting Pay

Ending Pay

Your Position and Duties

Reason for Leaving

Yes

No

May we contact this employer for a reference?

Military Service

Branch

From

To

Rank at Discharge:

Yes

No

Are you currently in the Armed Forces?

References

List below three persons not related to you who have knowledge of your work performance within the last three years.

Reference #1

First Name*

Last Name*

Phone*

Street Address*

City *

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code*

Occupation*

No. of Years Acquainted*

Reference #2

First Name*

Last Name*

Phone*

Street Address*

City *

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code*

Occupation*

No. of Years Acquainted*

Reference #3

First Name*

Last Name*

Phone*

Street Address*

City *

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code*

Occupation*

No. of Years Acquainted*

Please tell us why you believe you are a good candidate for this position.*

Please read carefully, check each box to acknowledge and submit.

I agree

I do not agree

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. *

I agree

I do not agree

I hereby authorize the Merced County Association of Governments to thoroughly investigate my references, work record, education and other matters related to my suitability for employment unless otherwise specified in writing. I further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Merced County Association of Governments, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure. *

I agree

I do not agree

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Merced County Association of Governments. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Merced County Association of Governments, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Merced County Association of Governments designated representative. *

I agree

I do not agree

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. *