Five County Association of Governments
Serving Beaver, Garfield, Iron, Kane and Washington Counties

Employment Application

PERSONAL INFORMATION	
     	
         Last Name                                                        First Name                                                         M.I.	
     	
Street Address                                                                               City                            State                           Zip	
Home Phone:		Cell Phone:  		E-Mail Address:		
Are you a U.S. Citizen?        Yes        No  	If no, are you eligible to work in the U.S.?        Yes        No  	

Have you ever been convicted of a felony?       Yes        No
If yes, please explain nature below.  (Convictions are evaluated for each position and are not necessarily disqualifying)

Position you are applying for:			If employed, are you willing to accept the approved salary for this position?            Yes      No  	
Available to work:           Full-Time         Part-Time         Seasonal	
Date available to start work:			Salary Desired:		
Have you ever been employed by Five County AOG before?    Yes    No    If Yes, when?	
	
EDUCATION	Have you graduated from high school or received a GED?      Yes      No
If no, circle the highest grade completed:   1   2   3   4   5   6   7   8   9   10   11   12	
School Name	Location	Major	Degree/Certificate Received 
or Years Attended	

				
Other training, certifications or licenses held:		

	
REFERENCES	List three people who are not related to you and who have definite knowledge of your qualifications for the position for which you are applying.	
Name	Present Business or Home Address	Business or Occupation	Phone Number 	

				

EMPLOYMENT HISTORY	
Beginning with present or most recent, list your three most significant employers.  If you wish to elaborate, a supplemental sheet or resume may be attached.  Include military service, if applicable.	
Employer Name:			Phone Number:		
Address:					
                                                                                                                                                                   	   Street Address                                                                                         City                              State               Zip	
Position Title:			Dates of Employment:	From		To		
Supervisors Name:			May we contact them?                                                 	  Yes       No	
Reason for Leaving:					Pay Rate:		
Duties Performed:	

	
Employer Name:			Phone Number:		
Address:					
                                                                                                                                                                   	   Street Address                                                                                         City                              State               Zip	
Position Title:			Dates of Employment:	From		To		
Supervisors Name:			May we contact them?                                                 	  Yes       No	
Reason for Leaving:					Pay Rate:		
Duties Performed:	

	
Employer Name:			Phone Number:		
Address:					
                                                                                                                                                                   	   Street Address                                                                                         City                              State               Zip	
Position Title:			Dates of Employment:	From		To		
Supervisors Name:			May we contact them?                                                 	  Yes       No	
Reason for Leaving:					Pay Rate:		
Duties Performed:	

	
Additional Qualifications, Skills or Languages:	

CERTIFICATION OF APPLICANT	
I certify that all statements made in this application are true and complete, and that any misstatements of material facts may subject me to disqualification or dismissal.  Also, I authorize verification of all statements made in this application.  I release Five County Association of Governments from any liability for the use of this information in considering and reviewing my application for the available position.  I understand that this employment application is not a contract of employment and that any oral or written statements to the contrary are hereby expressly disavowed.	
Signature of Applicant:		Date:	

Five County Association of Governments is an Equal Opportunity Employer
It is the policy of the Five County Association of Governments to provide and promote equal opportunity employment, compensation and other terms and conditions of employment without discrimination because of race, color, sex, religion, national origin, age or disability.  Five County Association of Governments provides reasonable accommodations to the known disabilities of applicants in compliance with the Americans with Disabilities Act.

Rev. 7/2014