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2. First Name*
3. Last Name*
5. Social Security Number*
6. Phone Number*
8. Email Address*
9. Fire/EMS Certification Number*
11. Current Address - Number and Street*
13. Address 2 (If Applicable)
15. City*
16. State*
17. Zip*
19. 7 Years of Prior Address History (If Applicable)
21. Prior Address 2 (If Applicable)
23. Prior Address 3 (If Applicable)
25. Are You An Adult?*

    1. Yes
    2. No
26. For what position(s) are you applying?*
28. Have you ever applied to or been employed by the state, a county, or any political subdivision thereof in Ohio? *

    1. Yes
    2. No
29. If yes, please explain:
31. Do you have any commitments (e.g., second job, school, etc.) which might interfere with, or adversely affect, your employment should we select you for a position? *

    1. Yes
    2. No
32. If yes, please explain:
34. Are you employed now?*

    1. Yes
    2. No
35. If so, may we contact your present employer?

    1. Yes
    2. No
37. Person to contact:
38. Phone number:
40. If we cannot inquire of your present employer, please explain why:
42. Are you on layoff and subject to recall?*

    1. Yes
    2. No
44. If employed, does your employment require you to continue working for your current employer, or restrict your activities after leaving your current employment, for any period of time?

    1. Yes
    2. No
45. If yes, until what date?
47. Are you prevented from becoming lawfully employed in this country because of VISA or immigration status? (Proof of citizenship or immigration status is required by federal law upon employment.)*

    1. Yes
    2. No
49. Do you possess a valid driver's license?*

    1. Yes
    2. No
50. State of Issuance
51. License Number
53. If no, can you obtain a driver’s license prior to employment?

    1. Yes
    2. No
54. Are you a resident of Ohio?*

    1. Yes
    2. No
56. Are you a veteran of the U.S. Military service? (Voluntary)

    1. Yes
    2. No
57. If yes, what Branch? (Voluntary)
59. Date you can begin employment:*
60. Salary desired:*
62. EMPLOYMENT HISTORY AND WORK EXPERIENCE
    IN THIS SECTION, LIST ALL EMPLOYMENT HISTORY AND WORK EXPERIENCE IN DATE ORDER. BEGIN WITH YOUR CURRENT EMPLOYER. FAILURE TO INCLUDE ALL EMPLOYMENT MAY BE GROUNDS FOR DISQUALIFICATION. ADDITIONAL EMPLOYERS CAN BE ADDED ON RESUME AT YOUR INTERVIEW.
64. Employer 1 - List Dates (Month and Year), Name and Address of Employer, Wage/Salary, Position and Reason for Leaving*
66. Employer 2 - List Dates (Month and Year) Name and Address of Employer, Wage/Salary, Position and Reason for Leaving
68. Employer 3 - List Dates (Month and Year) Name and Address of Employer, Wage/Salary, Position and Reason for Leaving
70. Employer 4 - List Dates (Month and Year) Name and Address of Employer, Wage/Salary, Position and Reason for Leaving
72. EDUCATION AND TRAINING
    THIS SECTION IS INTENDED TO GIVE THE EMPLOYER INFORMATION ABOUT THE EDUCATION AND TRAINING THAT THE APPLICANT HAS COMPLETED, AND TO DEMONSTRATE THE SKILLS, KNOWLEDGE, AND ABILITIES OF THE APPLICANT TO PERFORM THE JOB DUTIES OF THE POSITION. YOU MAY PROVIDE ADDITIONAL EDUCATIONAL BACKGROUND ON RESUME AT YOUR INTERVIEW.
74. High School - Please list name and location, if you graduated and the year.*
76. Trade, Business or Technical School - Please list name and location, if you graduated, year(s) and subject(s) studied
78. College - Please list name and location, if you graduated, year(s) and subject(s) studied
80. Other Special Study or Research Work - Please list name and location, if you graduated, year(s) and subject(s) studied
82. REFERENCES: Give the names of three (3) professional references, not related to you, whom you have known at least one (1) year.
84. Reference 1 - Name, Address, Phone Number, Occupation and Years Acquainted*
86. Reference 2 - Name, Address, Phone Number, Occupation and Years Acquainted*
88. Reference 3 - Name, Address, Phone Number, Occupation and Years Acquainted*
90. PLEASE USE THE FOLLOWING SPACE TO PROVIDE ANY FURTHER INFORMATION ON TRAINING, EDUCATION, CERTIFICATIONS, SKILLS, ABILITIES, HOBBIES, VOLUNTEER WORK, ETC., THAT YOU POSSESS OR HAVE EXPERIENCED THAT MAY BE HELPFUL IN THE EVALUATION OF YOUR APPLICATION.
92. PLEASE READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. INDICATE YOUR UNDERSTANDING OF, AND CONSENT TO, THE CONTENTS AND CONDITIONS OF EACH PARAGRAPH BY PLACING YOUR INITIALS AT THE END OF EACH PARAGRAPH. IF YOU HAVE ANY QUESTIONS REGARDING THESE PARAGRAPHS, CONTACT THE EMPLOYER BEFORE INITIALING THE PARAGRAPH.
94. 1. I understand and accept that, depending upon the position for which I am applying, if I am employed by Prairie Township, my employment may be for no definite period of time and may be terminated, with or without cause or notice at any time, at the option of either Prairie Township, or myself. I understand that no representative of Prairie Township, other than an appointing authority, has any authority to enter into any agreement or to make any agreement with me contrary to the foregoing, except that an appointing authority of Prairie Township may do so in writing under specific limited circumstances. Initials:*
96. 2. I understand and accept that, if I am selected for employment, my initial and continued employment may be conditioned upon my passing any medical examination that the employer deems necessary to determine whether I can physically perform the essential functions of the position, with reasonable accommodation when necessary. I understand and accept that this may include drug, alcohol, or substance abuse testing. Initials:*
98. 3. If employed, I understand and accept that, depending on the department in which I am applying for employment, I may be required to work evening or night shifts including weekends, be on call, and/or work mandatory overtime hours. I also understand and accept that I am required to abide by all rules and regulations of the Prairie Township appointing authority. Initials:*
100. 4. I 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 consideration. 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:*
102. 5. I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees. I also understand and accept that the various law enforcement and informational agencies that exchange information and data with the employer require that the employer's employees do not have a past record of unlawful activities. Therefore, I understand and accept that, depending on the department in which I am applying for employment, it may be necessary for the employer to investigate my background for any criminal or unlawful activity. Initials:*
104. 6. I hereby authorize the employers, schools, and personal references named in this application to provide information regarding me to the employer. I further authorize the release of personnel, academic, and other records to the employer. Initials:*
106. I 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 ANY MISREPRESENTATION OR FALSIFICATION OF THE INFORMATION PROVIDED MAY LEAD TO WITHDRAWAL OF AN EMPLOYMENT OFFER OR TERMINATION FOLLOWING EMPLOYMENT. I RECOGNIZE THAT MY FUTURE EMPLOYMENT WITH THE EMPLOYER WILL BE JEOPARDIZED IF I ENGAGE IN SUBSTANCE ABUSE, ILLEGAL DRUG USE, OR ALCOHOL ABUSE.
108. ***PLEASE READ CAREFULLY BEFORE SIGNING***
110. I AGREE THAT ANY CLAIM OR LAWSUIT RELATING TO MY EMPLOYMENT WITH THE TOWNSHIP OR ONE OF THE DEPARTMENTS MUST BE FILED NO MORE THAN SIX (6) MONTHS AFTER THE DATE OF THE EMPLOYMENT ACTION THAT IS THE SUBJECT OF THE CLAIM OR LAWSUIT. I WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY.
112. Please enter your full name as your electronic signature:*
113. Please enter today's date:*
     Please enter today's date:
115. EEO DATA: VOLUNTARY DISCLOSURE FORM
117. Regulations of the Equal Employment Opportunity Commission (EEOC) require employers to compile data regarding the nature and make-up of their work forces in order to further the goals of Title VII of the Civil Rights Act of 1964, as amended. Your responses to the following questions will help the employer comply with this requirement. Completion of this questionnaire is entirely voluntary on your part. Should you opt to complete the questionnaire, your response will be used by the employer solely for the purposes of preparing the reports required by the EEOC. Your response will be kept confidential, and will play no part in the employer’s evaluation of your employment performance or status, or your treatment as an employee. The completed questionnaire will be kept separate from your personnel file.
119. Name
120. Age
121. Sex
     -- Select One --FemaleMaleChoose Not To Disclose
123. RACIAL AND ETHNIC CATEGORIES:

     1. White (not of Hispanic origin)
     2. Black (not of Hispanic origin)
     3. Hispanic
     4. Asian or Pacific Islander
     5. American Indian or Alaska Native
125. Please upload your current Driver's License (front) here.*
126. Please upload your State Certification here.*
128. Please upload a resume.*
129. Please upload any other certifications or supporting documents here, if applicable.
Leave This Blank:


131. 1. Receive an email copy of this form.
132. Email address

     This field is not part of the form submission.

133. Submit

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