POTTER COUNTY 1NORTHI MAINST. COUDERSPORT, PA 814-274-8290  EmploymentApplication  Wea are an Equal Opportunity Employer. Please complete entire application and: sign ati the end.  APPLICANT INFORMATION  DATE:  NAME  First  middle  last  ADDRESS  street  city EMAIL  state  zip code  PHONE NUMBER  Arey youl legallya authorized to worki int the U.S.? (IFH hired, youy willl be required top provide proof of work authorization.)  D Yes D No LZJ Yes No DYes No  Arey you: atl least: 18y years ofa age? validv workp permit.)  (Ifn not,) your employment willl bes subjectt to verification: thaty your meet state/lederalminimum: age requirements fort thet typec ofv work youa are applying for and have obtaineda Ifyes, please explain 1) nature of crime, 2) date of conviction, 3)s state and countyi in which convicted. (A conviction will not necessarily bar youf from  Havey youe ever pleaded "guilty" or' no contest" orb been convicted ofac crime? ment. Yous shouldr not disclose anyi information regarding criminalr recordst thath have been sealed.)  employ-  Havey youe ever appliedi for ap position with Potter County before? Yes ONo Ifyes, when: Willy yout travel ifj jobr requires it? D Yes  No POSITION APPLVING FOR  Havey you ever worked for Potter County before? Yes No Ifyes, when: Willy you work overtime if required? Yes ONo  Under what name:.  POSITION SHIFT PREFERENCE WHEN CAN YOUSTART?  Part-Time DESIRED COMPENSATION  DFull-Time  HOW' WERE YOU REFERRED TO THIS POSITION?  Walk-In  DNewspaper  Internet DOther  DAgency (ex: CareerLink)  OFriend/Relative School    SPECIALSKILLS  Please listanys skills you possess that. would be valuable to the position you are applying for.  EDUCATION SCHOOL NAME  LOCATION (CITY,STATE)  NO.YEARS ATTENDED  MAJOR SUBJECTS  DIPLOMA OR DEGREE RECEIVED  High  DYes No  College  OYes Type:  D No  Graduate  Yes ONo  Type:  Other (specify)  Yes ONo  Type:  RELEVANT TRAINING  Please list any relevant training courses/programs completed.  DATE(S) ATTENDED DATE(S) ATTENDED DATEIS/ATTENDED  Are you licensed/have certifications which will assist in the job? Please explain.  Yes ONo EXPIRATION DATE  LICENSE/CERIFCATION NUMBER  STATE ISSUED    EMPLOYMENT HISTORY NAME OF EMPLOYER ADDRESS JOBT TITLE  Start with most recent; use: separate: sheeti if necessary.  TELEPHONE  EMPLOYMENT DATES (month and year)  From  To.  DESCRIPTION OF DUTIES  NAME OF IMMEDIATE SUPERVISOR  REASON FOR LEAVING  COMPENSATION NAME OF EMPLOYER ADDRESS JOBTITLE  start  end.  TELEPHONE  EMPLOYMENT DATES (month and year)  From,  To  DESCRIPTION OF DUTIES  NAME OF IMMEDIATE SUPERVISOR  REASON FOR LEAVING  COMPENSATION NAME OF EMPLOYER ADDRESS JOB TITLE  start  end  TELEPHONE  EMPLOYMENT DATES (month and year)  From  To  DESCRIPTION OF DUTIES  NAME OF IMMEDIATE SUPERVISOR  REASON FOR LEAVING  COMPENSATION  start  end    EMPLOYMENT REFERENCES  Listi individuals familiar withy your job qualifications. (other than relatives or personal friends).  NAME ADDRESS  RELATIONSHIP  HOW LONG KNOWN?. NAME ADDRESS  TELEPHONE DAY_  EVENING  RELATIONSHIP  HOWLONGI KNOWN?. NAME ADDRESS  TELEPHONE DAY  EVENING  RELATIONSHIP  HOWLONG KNOWN?  TELEPHONE DAY  EVENING.  Please Read Carefully Before Signing This Form  1. Alli information contained int this applicationi ist true ando correct tot theb best of my! knowledge and belief. lunderstand that misrepresentations or omis- sions ofa anyk kindr may resulti inc denial ofe employment or be cause for subsequent dismissal iflam! hired, regardless of when suchi information is dis- 2. lauthorize Potter County toi investigate my responses ont this application and contact any ora all of my former employers or anyi individuals familiar withr me orr mye employment backgroundi for the purpose of verifying anyi information! Ihavep provided and/ori for the purpose of obtaining anyi infor- mation, whetheri favorable or unfavorable, aboutr me or mye employment. voluntarily and knowingly fully release and hold harmless any persons or 3. Lunderstand that uponr receiving a job offer, ap physical examination and drug screening may ber required. (Note: If this is aj jobr requirement, you will 4. understand that priort tor mye employment Imay be asked to: signa a background check consent form or other documentation in order tof facilitate my 5. lunderstand thatt this application remains current for only 90 days. Att the conclusion of that time, ifihaver not heard from the employer and still wish 6. Potter County does not tolerate unlawful discrimination ini its employment practices. No question ont this application is used for the purpose of limiting ore excluding an applicant from consideration for employment ont the! basis of! his or hers sex, race, color, religion, national origin, citizen- ship, age, disability, or any other protecteds status under applicable federal, state orl locall law. The Company likewise does not tolerate harassment based ons sex, race, color, religion, national origin, citizenship, age, disability or any other protected status. Examples of prohibited harassment include, buta are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name- calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that de- mean, stigmatize, intimidate, or single out a person! because of his/her membership ina a protected category. Harassment of our employees is strictly prohibited, whether iti is committed! bya a manager, coworker, subordinate or non-employee (such as a vendor or customer). Potter County 7. Regardless of whether or not! become employed by Potter County,! recognize that this applicationi is not and: shouidr not be considered a contract of employment. understand1 that employment with Potter County is on ana at-will basis and that my employment: may bet terminated with orv without cause, and without notice, at anyt time, atr my option or Potter County's, unless specifically provided otherwise inav written employment contract.I further understand that not Potter Countye employee orr representative has the authoritytoe enteri into a contract regarding duration or terms and con- ditions ofe employment other than and officer or official of Potter County, and then only by means ofa signed, written document.  covered.  organizations providing information pertainingt tor me or my employment.  ber notified.)  hiring. tagree to signt thesef forms.  tol be considered: for employment, itv willl be necessary for me to reapply andi fillo out a new application.  takes allo complaints of harassment seriously and all complaints willE be investigated promptly and thoroughly.  SIGNATURE OFA APPLICANT.  DATE  THANK YOUFOR' YOUR INTEREST IN WORKING FORI POTTER COUNTY.