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Putnam County District Library
Applicant Information
Last Name First M.I. Date
Street Address Apartment/Unit #
City State ZIP
Phone E-mail Address
Date Available Social Security No. Desired Salary
Position Applied for
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 worked for this company? YES NO If so, when?
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
References
Please list three professional references.
Full Name Relationship
Company Phone ( )
Address
Full Name Relationship
Company Phone ( )
Address
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? YES NO
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? YES NO
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? YES NO
Military Service
Branch From To
Rank at Discharge Type of Discharge
If other than honorable, explain
DISCLAIMER AND SIGNATURE
I certify that answers given herein are true and I agree and understand that any false or misleading statement contained herein may cause rejection of this application or termination of employment. I authorize the Putnam County District Library to contact my current and past employers and personal references, and to investigate all statements contained in this application for employment. I understand that I will have to provide acceptable documentation attesting that I am a U.S. Citizen or legal immigrant eligible for work in the United States. I also understand that I will not be hired until I have successfully completed the employment process, including a criminal background investigation. The cost of the criminal background investigation will be approximately $75 and will be paid for by the applicant. The results of the criminal background investigation will be used by the Putnam County District Library to ascertain the eligibility, appropriateness or fitness of all applicants for work within the Library. I understand that this application is not a contract for employment. I understand that any oral or written statement to the contrary is expressly disavowed, and should not be relied upon by any prospective or existing employee. I hereby understand and acknowledge that, unless otherwise defined by applicable law, my employment with this organization is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge the employee 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 the Putnam County District Library. I understand that I am required to abide all rules and regulations of the employer.
Signature Date