Online Application

APPLICATION INFORMATION

Date:

Name
Last Name:

First Name:

Middle:

Address
Street:

Apartment:

City:

State:

Zip:

Phone:

Email:

Date Available:

Social Security Number:

Desired Salary:

Position Applied for:

Are you a citizen of the United States? YesNo
If no, are you authorized to work in the U.S.? YesNo
Have you ever worked for this company? YesNo
If yes, When?
Have you ever been convicted of a felony? YesNo
If yes, explain:

EDUCATION

High School:

Address:

From:

To:

Did you graduate?: YesNo
Diploma:

REFERENCES

Please list three professional references. Please do not include relatives or former employers.

Full Name:

Relationship:

Company:

Phone:

Address:

PREVIOUS EMPLOYMENT

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference? YesNo

MILITARY SERVICE

Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

WORK AVAILABILITY

If your application receives favorable consideration, when will you be available to begin work?

Do you have any objection to working overtime? YesNo
Can you work overtime without prior notice? YesNo
Can you work on Saturday? YesNo
Can you work on Sunday? YesNo
Can you work on Holidays? YesNo

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature: By typing your name on this line we will accept this as a signature.

Date:

ROBERTSON COUNTY E-911 - BACKGROUND RESEARCH RELEASE

Please read this section carefully and acknowledge your understanding by signing your name in the space below.
I certify that all of the statements made by me on this application for employment are true, correct, and complete to the best of my knowledge.

1. Consent To Conduct Background Investigation
As a condition for Robertson County E-911’s consideration of this application, I give permission to Robertson County E-911 to investigate my personal and employment history. I understand that this background investigation will include, but not be limited to, verification of all information on this application, as well as interviews with past employers. I further give permission to Robertson County E-911 to conduct this investigation and to discuss the results of this investigation in connection with my application for employment.

2. Consent To Contact Past Employers
I give permission to Robertson County E-911 to contact all employers listed in this application, except those specifically excluded for references. I further give permission to all current or previous employers and their designees to discuss my relevant personal and employment history with Robertson County E-911, consent to the release of such information orally or in writing, and hereby release them from all liability and agree not to sue them for defamation or other claims based upon any statements they make to any representative of Robertson County E-911. I further waive all rights I may have under law to receive a copy of any written statement provided by any of my former employers to Robertson County E-911. I further agree to indemnify all current and past employers for any liability they may incur because of their reliance upon this release.

3. Consent To Contact Government Agencies
I give permission to any agent, attorney or representative of Robertson County E-911 to receive a copy of any information obtained in the file of any federal, state or local court, governmental agency, law enforcement agency or investigator relating to me. I further consent to the release of such information and waive any right under law concerning notification of the request for a release of such information. In the event a law does not provide for prospective employers to have access to information, I hereby delegate Robertson County E-911 as my agent for receipt of information. I understand that the scope of this investigation will be limited to criminal and/or civil records that relate to my honesty, integrity and/or abilities.

4. Cooperation With Investigation
I agree to fully cooperate in Robertson County E-911's background investigation, and to sign any waivers or releases that may be necessary to obtain access to relevant information. In the event that any former employer or federal, state or local governmental agency will not release reference information or criminal history information directly to Robertson County E-911, I agree to personally request such information to the extent permitted by law.

5. Falsification Statement
I understand that any falsification or willful omission of fact made in this application or in connection with any background investigation may be sufficient grounds for rejection of this application, or, if discovered after an offer of employment, for immediate dismissal.

6. Employment
In consideration of my employment, I agree to conform to the rules and regulations of Robertson CountyE-911.

Signature: By typing your name on this line we will accept this as a signature.

Date:

[recaptcha]