Application For Employment
PLATTE COUNTY, MISSOURI IS AN EQUAL OPPORTUNITY EMPLOYER
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Position(s) Applied For *
Date of Application *
MM
/
DD
/
YYYY
Address *
Email Address *
Home/Mobile Telephone *
Work Telephone *
Social Security Number *
If you are under 18 years of age, can you provide required proof of your eligibility to work?
Clear selection
Have you filed an application with Platte County Previously? *
If yes, when?
Have you been employed by Platte County previously? *
If yes, when?
Are you currently employed? *
May we contact your present employer? *
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? *
On what date would you be available for work? *
MM
/
DD
/
YYYY
Are you available to work: *
Required
Are you currently on "lay-off" status and subject to recall? *
Driver's License number (if driving is an essential job function)
Do you have a CDL?
Clear selection
If yes, which class?
Have you been convicted of a felony?
Clear selection
If yes, please explain:
Is there any reason you could not perform the essential functions of the position for which you are applying without reasonable accommodations?
Clear selection
If yes, please explain
EMPLOYMENT EXPERIENCE
START WITH YOUR PRESENT OR LAST JOB. INCLUDE ANY JOB-RELATED MILITARY SERVICE ASSIGNMENTS AND VOLUNTEER ACTIVITIES. YOU MAY EXCLUDE ORGANIZATIONS WHICH INDICATE RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, DISABILITIES, OR OTHER PROTECTED STATUS.
Employer 1
Employer Name
Address
Telephone Number
Job Title
Supervisor
Reason for leaving
Dates Employed
From
MM
/
DD
/
YYYY
To
MM
/
DD
/
YYYY
Hourly Rate/Salary
Starting
Final
Work Performed
Employer 2
Employer Name
Address
Telephone Number
Job Title
Supervisor
Reason for leaving
Dates Employed
From
MM
/
DD
/
YYYY
To
MM
/
DD
/
YYYY
Hourly Rate/Salary
Starting
Final
Work Performed
Employer 3
Employer Name
Address
Telephone Number
Job Title
Supervisor
Reason for leaving
Dates Employed
From
MM
/
DD
/
YYYY
To
MM
/
DD
/
YYYY
Hourly Rate/Salary
Starting
Final
Work Performed
Employer 4
Employer Name
Address
Telephone Number
Job Title
Supervisor
Reason for leaving
Dates Employed
From
MM
/
DD
/
YYYY
To
MM
/
DD
/
YYYY
Hourly Rate/Salary
Starting
Final
Work Performed
Education
Do you have a high school diploma or equivalent? *
If not, what is the highest grade you completed?
PLEASE LIST ALL EDUCATION, BEGINNING WITH SCHOOL
High School:
Name and location
Degree
Clear selection
Technical/Vocational:
Name and location
Course of study
Total hours
Degree
Clear selection
College:
Name and location
Course of study
Total hours
Degree
Clear selection
SKILLS AND CERTIFICATIONS
List all valid professional licenses and registrations you hold. Include the certification/registration number and the date of expiration.
Indicate other employment skills, special training or additional information to consider regarding your application. (You may exclude all information indicative of age, sex, race, religion, color, national origin, or disability.)
REFERENCES
PLEASE LIST THREE PEOPLE WHO WE MAY CONTACT TO VERIFY INFORMATION CONTAINED WITHIN THIS EMPLOYMENT APPLICATION.
Reference #1
First Name
Last Name
Phone Number
Address
Reference #2
First Name
Last Name
Phone Number
Address
Reference #3
First Name
Last Name
Phone Number
Address
Applicant's Statement
I CERTIFY THAT THE ABOVE STATEMENTS ARE CORRECT, AND IF EMPLOYED, UNDERSTAND THAT ANY FALSE INFORMATION IN THIS APPLICATION, OR ITS SUPPORTING DOCUMENTS, WILL BE SUFFICIENT GROUNDS FOR TERMINATION WITHOUT NOTICE. I FURTHER AGREE THAT ALL RULES, ORDERS AND REGULATIONS OF PLATTE COUNTY AFFECTING MY EMPLOYMENT SHALL CONSTITUTE A PART OF MY APPOINTMENT OR EMPLOYMENT.
I HEREBY UNDERSTAND AND ACKNOWLEDGE THAT, UNLESS OTHERWISE DEFINED BY APPLICABLE LAW, ANY EMPLOYMENT RELATIONSHIP WITH PLATTE COUNTY IS OF AN "AT WILL" NATURE, MEANING THAT I CAN RESIGN AT ANY TIME AND THAT I MAY BE DISCHARGED AT ANY TIME, WITH OR WITHOUT CAUSE. IT IS FURTHER UNDERSTOOD THAT THIS "AT WILL" EMPLOYMENT RELATIONSHIP MAY NOT BE CHANGED BY ANY WRITTEN DOCUMENT OR BY CONDUCT UNLESS SUCH CHANGE IS SPECIFICALLY ACKNOWLEDGED IN WRITING BY AN AUTHORIZED EXECUTIVE OF PLATTE COUNTY.
MY SIGNATURE AUTHORIZES PLATTE COUNTY TO REVIEW MY PREVIOUS EMPLOYMENT, DRIVING AND CRIMINAL RECORDS, AND OTHER BACKGROUND DATA AS IT RELATES TO THE POSITION(S) FOR WHICH I AM APPLYING.
Electronic Signature
Platte County requires that you certify your application by submitting an electronic signature. To certify your application, provide an electronic signature (type your name) and enter today's date, then click Submit.
Signature *
Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Platte County, Missouri. Report Abuse
Google Forms