PERSONAL DATA:

First Name:                                                                                                         Last Name:                                                                                                           Middle Initial:
      
Street Address:                                                                                                                       Apartment/Unit #
   
City:                                                                                                                         State:                                                                                              Zip:
      
Primary Phone:                                                                                                Alternative Phone:                                                                     
    
Email: 

Date Available:                                                                                                  Desired Salary:
   
Are you a citizen of the United States?    Yes      No            
If no, are you authorized to work in the U.S.?    Yes      No
Have you ever been convicted of a felony?   Yes      No      If yes, explain here:   

Did you graduate High School or have you obtained a G.E.D.?   Yes     No

How long have you lived at your current address?                    If less than 10 years, list your previous address and how long you lived there.
                                               

Have you applied with Vernon County before?   Yes      No    If yes, give date:  

Have you ever been employed with Vernon County?   Yes      No
If you have been employed with Vernon County, please provide the date, department and under what name you were employed:
 

Are you currently employed?   Yes     No

Are you at least 18 years old?   Yes      No

Are you currently a member of any reserve?   Yes     No

Where did you first hear about this job opportunity?           Vernon County Website
                                                                                                                                Facebook
                                                                                                                                Indeed
                                                                                                                               Other   

EDUCATION:

High School:                                                                                                         Address:
    
Did you graduate?   Yes    No                                         
Degree:  


College:                                                                                                                   Address:
     
From:                                                   To:              
    
Did you graduate?   Yes    No
Degree: 


Other:                                                                                                                      Address:                                                      
    
From:                                                   To:              
   
Did you graduate?   Yes    No
Degree: 
                                                                                                                                                                                                           

Previous employment

EMPLOYER 1
Company:                                                                                                              Phone:
    
Address:                                                                                                                 Supervisor:
    
Job Title:                                                                                                                Starting Salary:                                  Ending Salary:
            
Responsibilities:

From:                           To:                                   Reason for Leaving:
      
May we contact for reference?   Yes     No

EMPLOYER 2
Company:                                                                                                              Phone:
    
Address:                                                                                                                 Supervisor:
    
Job Title:                                                                                                                Starting Salary:                                  Ending Salary:
            
Responsibilities:

From:                           To:                                   Reason for Leaving:
      
May we contact for reference?   Yes     No

EMPLOYER 3
Company:                                                                                                              Phone:
    
Address:                                                                                                                 Supervisor:
    
Job Title:                                                                                                                Starting Salary:                                  Ending Salary:
            
Responsibilities:

From:                           To:                                   Reason for Leaving:
       
May we contact you for reference?   Yes     No

COMMENTS:
Including explanation of gaps in employment.  

REFERENCES:

REFERENCE 1
Full Name:                                                                                                            Relationship:
    
Company:                                                                                                              Phone:
    
Email:

REFERENCE 2
Full Name:                                                                                                            Relationship:
    
Company:                                                                                                              Phone:
    
Email:


REFERENCE 3
Full Name:                                                                                                            Relationship:
   
Company:                                                                                                              Phone:
   
Email:

Military service:
Branch:                                                                                                                   From:                            To:
        
Rank at Discharge:                                                                                          Type of Discharge:
    
If other than honorable, explain:

Skills & qualifications:
Describe any specialized training, apprenticeship, job-related skills and extra-curricular activities:
(equipment operated, CDL, software programs, foreign languages, professional licenses/certificates, etc.)

I understand and acknowledge that I am providing a complete list of all my full and part time employment for the past TEN YEARS FROM TODAY'S DATE, and that I have not omitted any jobs in my work history. I understand that I should include any work experience beyond ten years if it is reasonably related to the position for which I am applying. I understand that I am to include military service, if any, in my ten year work history.

I understand and acknowledge that I must fill out the application completely even if a resume is attached, that "see resume" should not be used for responses to questions contained in this application and that a resume is not to be used as a substitute for completion of the application form and questions.

Vernon County has zero tolerance for use or possession of illegal drugs. The policy also covers drug use or alcohol intoxication of any amount while on the job, and smelling of alcohol while on the job. I consent/agree to pre-employment drug and alcohol testing, reasonable suspicion drug and alcohol testing of my breath, urine and blood during my employment. I understand that a positive test may void my application. I understand that after hire a positive test or policy violation may result in discipline up to and including discharge.

Public Records Notice:  Wisconsin Statutes require application materials to be open records unless you request confidentiality. Your application materials will be kept confidential, however, the law requires your information to be public record if you become a finalist unless you withdraw your application. You will be notified before your application is made public. 

 I have read, understand and agree to the above.

Upload resume and/or cover letter: (txt, pdf)

Resume/Cover Letter:

As employers/government contractors, we comply with government regulations and affirmative action responsibilities. Solely, to help us comply with government record keeping, reporting and other legal requirements, please fill out the Data Record. This Data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment. Government agencies require periodic reports on the gender, ethnicity, handicapped and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information in this section is optional.

Check One:
 Male      Female

Check one of the following:
Please select one: White (not Hispanic) Black (not Hispanic) Hispanic Asian or Pacific Islander American Indian or Alaskan Native

Chick if any of the following are applicable:
 Disabled Veteran
 Handicapped Individual
 Vietnam Era Veteran

certification and agreement:

I certify that answers herein are true and complete; furthermore, I understand that misrepresentation or omission of facts in this application or during an interview(s) will be cause for cancellation of consideration for employment or dismissal if employed. I certify that any resume or additional information attached is true and complete and that any misrepresentation or omission of facts on these documents will be cause for cancellation of consideration for employment or dismissal if employed.

I authorize an inquiry to be made on the information contained in this application, and I understand for some positions this may include a thorough background investigation. Upon written request, the nature and scope of this inquiry will be made available to me. Former employers named herein are authorized to give information regarding me. They are hereby released from all liability for furnishing such information to Vernon County.

I understand that employment is contingent upon a favorable evaluation and/or results of any pre-employment requirements necessary to perform the position applied for. This may include a health evaluation form, medical examination, alcohol and controlled substance testing, skills testing, aptitude testing, verification of employment or other assessment determined necessary.

This application for employment shall be considered active for the period of time the position applied for is vacant. Any applicant wishing to be considered for employment beyond this time period should reapply.

In addition a copy of this authorization is a valid as the original and should be recognized as such.

 NOTICE TO APPLICANTS:  The authorization below may be photocopied and sent to previous employers for the purpose of obtaining information regarding previous employment.

 IF YOU BECOME A FINALIST FOR THE POSITION, YOUR IDENTITY MAY BE DISCLOSED AS REQUIRED BY LAW.

 NOTICE TO APPLICANTS Wisconsin Statues, Sections 19.36 (7), allows the identity of an applicant to remain confidential if the applicant requests in writing that the county not provide access to this information. If you choose not to have this information become a public record, you must make such a request in writing to the Personnel Department. 

 I have read, understand, and agree to the above.

Sign and date:
Warning: Vernon County requires that you certify your application by submitting an electronic signature. To certify your application, type your FULL LEGAL NAME AND TODAY'S DATE and click "Submit Application".

Full Legal Name:   

Date: