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HomePhoneNumber  v .  #XPX#XXPMAILINGADDRESS(Street)     z2  #XPX#XXPWorkPhoneNumber(Maywecallyouhere?)   #XPXR#XXP    (City)(State)(ZipCode) v  #XPX#XXP    EmailAddress(Doyoucheckmessagesoften?) v   ̀Pleaselistanyothernamesusedifdifferentfromnamegivenonapplication_______________________________________________________ f *xX dddd  dd XX%X%x,dd , dd +   LISTEXACTTITLEOFPOSITIONFORWHICHYOUWISHTOAPPLY: r*    MINIMUMSALARYDESIRED: r* $  #XPX #XXPԀ #XPXC # XXPHaveyoueverbeenconvictedofafelony?Yes#XPX  # XXPԀNo#XPX  # XXPIfyouransweris"Yes",explaininconcisedetailona j separatesheetofpaper,givingthedateandnatureoftheoffense,thenameandlocationofthecourt,andthedispositionofthecase(s).Aconviction ~ maynotdisqualifyyou,butafalsestatementwill.Note:Somepositionsrequireinformationaboutmisdemeanorconvictionsordeferredadjudication. v.  ̀#XPXQ #XXPԀEDUCATION(Note:Applicantsmayberequiredtoprovideproofofdiploma,degree,transcripts,licenses,certificationsandregistrations.) " #XPX@#XXP̀CircleHighestGradeCompleted:123456789101112Didyougraduate/achieveGED?Yes#XPX##ԀXXPԀNo#XPX# 6$ *xXdddd  dd X X%X%x,fdd ,dd ,dd ,/dd ,dd ,dd ,dd ,dd ,dd ,dd +  *e"%" *XXPTypeof 6' School Me8)(RRe MName& 6* LocationofSchool VeA2+"RRe VDatesAttended He3$>,"e H#Semester >- Hours 6. Completed VeA2/"RRe VGraduated? He3$>0"e HExpected >1 Graduation 62 Date VeA23"RRe VTypeof >4 Diplomaor 65 Degree VeA26"RRe VMajor/Minor >7 Fieldof 68 Study B829"RRe B  t,9  ,e t,9 ,#XPX#XXPFrom Ae,!:"e AЀTo 1'!;"e 1 ,e t,; ,Yes Ae,!<"e AЀNo 1'!="e 1  t,=   t,=  'e t,= '#XPXx#XXPUndergraduate *> College(s)or ? University(s)  B@  5+):!A e 5#XPX8# XXP  *B   *C   *D   *E   *F   *G   *H   *I #XPX #XXP  *J    J #XPX# XXP   :K    :L    :M    :N    :O    :P    :Q    :R #XPX r#XXP   :S   v!.S #XPX\# XXP  !T   !U   !V   !W   !X   !Y   !Z   ![ #XPX #XXP $e !\ $Graduate 2#] School(s) 5+)# ^  e 5#XPX# XXP  2#_   2#`   2#a   2#b   2#c   2#d   2#e   2#f #XPX {#XXP  2#g   &$ g #XPXe# XXP  $B!h   $B!i   $B!j   $B!k   $B!l   $B!m   $B!n   $B!o #XPX #XXP $e $B!p $Technical, %"q Vocationalor &J#r Business B'#s School(s) 5+)'$t 8 e 5#XPX # XXP  %"u   %"v   %"w   %"x   %"y   %"z   %"{   %"| #XPX !#XXP  %"}   &#} #XPX"# XXP  :'#~   :'#   :'#   :'#   :'#   :'#   :'#   :'# #XPX !##XXP  :'#   .($ #XPX $# XXP  (J%   (J%   (J%   (J%   (J%   (J%   (J%   (J% #XPX ~$#XXP (J% #XPXh%#XXP̀Ifalicense,certificate,orotherauthorizationisrequiredorrelatedtothepositionforwhichyouareapplying,completethefollowing: 6*& *Xd dfdd fdd dd /dd /dd dd dd dd dd dd XX%X%,4dd ,dd ,4dd ,dd , dd +  &e*'*' &LICENSECERTIFICATION /eJ+(e /DateIssued /eJ+(e /IssuedBy(StateorAuthority) /eJ+(e /LicenseNo. /eJ+(e /LocationofIssuingAuthority(City/State) $J+(e $  ,F)   ,F)   ,F)   ,F)   ,F)   -*   -*   -*   -*  -*  #XPX%#  sHXXPPage1of5  .j+ P P  H P  #XPXsH*# NXXP    EMPLOYMENTHISTORY#XPX Ni+#sHXXP H +#XPXsH+#XXPThisinformationwillbetheofficialrecordofyouremploymenthistoryandmustaccuratelyreflectallsignificantdutiesperformed.Summaryof   experienceshouldclearlydescribeyourqualifications.Aresumemaybeattached,butnotsubstitutedfortherequestedinformation.  1.0  IncludeALLemployment.Beginwithyourcurrentorlastpositionandworkbacktoyourfirst.0%% 2.0  Employmenthistoryshouldincludeeachpositionheld,eventhosewiththesameemployer.%% 3.0  Giveabriefsummaryofthetechnicaland,ifappropriate,themanagerialresponsibilitiesofeachpositionyouhaveheld.H%% Ifyouneedadditionalspacetoadequatelydescribeyouremploymenthistory,youmayusethisemploymenthistorysheetorattachatypewritten    historyprovidingthesameinformationinthesameformatastheapplicationform.  X  *Xdd4dd 4dd 4dd 4dd  dd XX%X%,z dd ,dd ,dd +      NAMEOFEMPLOYER(Current/Last) d      |  ADDRESS  d   TELEPHONENUMBER d   *Xddz dd z dd dd XX%X%, dd ,dd , dd ,dd +  \ \  EMPLOYED(Mo.&Yr.)   _________________________ h  FromTo    PAYRATE   __________________ h  StartFinish    REASONFORLEAVING    SUPERVISOR   #XPX=,#*Xdd dd  dd  dd  dd XX%X%,edd ,dd +   XXPFulltime#XPX5#XXPԀ \ Parttime#XPX5#XXP  Temporary#XPXc6#XXP  L  JOBTITLE&RESPONSIBILITIES(Useadditionalpagesifnecessary) \! #XPX6# &  XXP  #XPX 7# XXP*x)X*ddedd edd XX%X%x,z dd ,dd ,dd +  d'd  NAMEOFEMPLOYER (   p(* ADDRESS  + TELEPHONENO. , *-X.ddz dd z dd dd )X*X%X%, dd ,dd , dd ,dd +  P,P EMPLOYED(Mo.&Yr.) l- _________________________ / FromTo  |0 PAYRATE l1 __________________ 3 StartFinish  |4 REASONFORLEAVING# 8#  l5  SUPERVISOR# <# l6 */X0dd dd  dd  dd  dd -X.X%X%,edd ,dd +  \6\  Fulltime# e=# Ԁ 7 Parttime# =#  |49 Temporary# >#    ; JOBTITLE&RESPONSIBILITIES(Useadditionalpagesifnecessary) < # ># x!0A *x+X,ddedd edd /X0X%X%x,z dd ,dd ,dd +  0#B0#  NAMEOFEMPLOYER #L C   $!E ADDRESS  #L F TELEPHONENUMBER #L G *3X4ddz dd z dd dd +X,X%X%, dd ,dd , dd ,dd +  %"G%" EMPLOYED(Mo.&Yr.) 8&"H _________________________ 'P$J FromTo  H(%K PAYRATE 8&"L __________________ 'P$N StartFinish  H(%O REASONFORLEAVING# D@#  8&"P  SUPERVISOR# YC# 8&"Q *1X2dd dd  dd  dd  dd 3X4X%X%,edd ,dd +  ()%Q()%   Fulltime# D# Ԁ )D&R Parttime#  E#  +'T Temporary# vE#   t,,)V JOBTITLE&RESPONSIBILITIES(Useadditionalpagesifnecessary) )D&W # E#,)\    sH Page2of5# sHF# @.*\ F  .+] F F  H F      EmploymentHistoryContinued#  G#sH   # sHH#G*x5X6ddedd edd 1X2X%X%x,z dd ,dd ,dd +    NAMEOFEMPLOYER Fv    ADDRESS  Fv TELEPHONENUMBER Fv *?X@ddz dd z dd dd 5X6X%X%, dd ,dd , dd ,dd +   EMPLOYED(Mo.&Yr.)  _________________________ Jz  FromTo  *  PAYRATE   __________________ Jz  StartFinish  * REASONFORLEAVING# jI#    SUPERVISOR# L#  *GXHdd dd  dd  dd  dd ?X@X%X%,edd ,dd +      Fulltime# M# Ԁ > n Parttime# .N#    Temporary# N#   & V  JOBTITLE&RESPONSIBILITIES(Useadditionalpagesifnecessary) > n # N#   *x7X8ddedd edd GXHX%X%x,z dd ,dd ,dd +  f f   NAMEOFEMPLOYER     *Z ADDRESS    TELEPHONENUMBER  ! *AXBddz dd z dd dd 7X8X%X%, dd ,dd , dd ,dd +   :! : EMPLOYED(Mo.&Yr.) n" _________________________ $ FromTo  ~% PAYRATE n& __________________ ( StartFinish  ~) REASONFORLEAVING# P#  n*  SUPERVISOR# S# n+ *IXJdd dd  dd  dd  dd AXBX%X%,edd ,dd +  ^+^  Fulltime# /U# Ԁ , Parttime# U#  6f. Temporary# U#   0 JOBTITLE&RESPONSIBILITIES(Useadditionalpagesifnecessary) 1 # PV# 2b6 *x9X:ddedd edd IXJX%X%x,z dd ,dd ,dd +  7  NAMEOFEMPLOYER N~8   : ADDRESS  N~; TELEPHONENUMBER N~< *CXDddz dd z dd dd 9X:X%X%, dd ,dd , dd ,dd +  < EMPLOYED(Mo.&Yr.) "= _________________________ R? FromTo   2@ PAYRATE "A __________________ RC StartFinish   2D REASONFORLEAVING# X#  "E  SUPERVISOR# #[# "F *KXLdd dd  dd  dd  dd CXDX%X%,edd ,dd +   F   Fulltime# \# Ԁ F!vG Parttime# \#  "I Temporary# ;]#   .$^!K JOBTITLE&RESPONSIBILITIES(Useadditionalpagesifnecessary) F!vL # ]# $!Q  MILITARYSERVICE(AcopyofDD214reportfromtheArmedServicesmayberequired). n&#R DatesofService(From/To)_______________________________________Branch_____________________________________________ '$T # r^# SPECIALSKILLS/QUALIFICATIONS .)^&V # _# Doyoutype?Yes# `# ԀNo# w`# Ԁ_________WPM;DoyouspeakalanguageinadditiontoEnglish?PleaseList__________________________ *'X Listanyequipmentormachineswithwhichyouareproficient__________________________________________________________________# `#  ,2)Z Listanycomputersoftwarewithwhichyouareproficient_____________________________________________________________________ b-*\   # b#sH Page3of5# sHb#  N/~,_ (_J (9 (  b    KENTCOUNTY,DELAWARE#  c#  9 PERSONNELOFFICE M KentCountyAdministrativeComplex,Room213  555BayRoad,Dover,Delaware19901  (302)7442310,Fax(302)7362262 ` www.co.kent.de.us ]$ c      &W % THANKYOUforconsideringemploymentwithKentCountyLevyCourt.Ourhighlyprofessionalorganizationiscommitted  topublicserviceandmeetingtheneedsofourcitizensandvisitors.Wehopeyoufindourextensiveapplicationprocessto   beuncomplicated.Dependingonthenumberofapplicationsandanyexaminationrequirements,westrivetocompletethe  \  entirehiringprocesswithinonemonthofthepositionclosing.TheCountyselectsthebestandmostqualifiedcandidatefor m 4  eachvacancy,withoutregardtofamilialorpoliticalaffiliationorinfluence.IfyouhavequestionsaboutKentCountys E  hiringprocedures,pleasecontactus.   `e  #  %&Wle#PersonnelDirector   h    *MailorbringyourcompletedapplicationtotheKentCountyPersonnelOfficeattheaddresslistedabove.ThePersonnelOffice }D  cannotberesponsibleforapplicationssentdirectlytodepartments,individualsorotherpublicorprivateagencies. A  *Applicationsareonlyacceptedforvacantpositions.Allapplicationsareretainedforaperiodofonecalendaryearfromdateofreceipt.  Ifyouareinterestedinafuturevacancy,youmaycontactthePersonnelOfficeandrequestsubmissionofthisapplication. T *EmployeesofKentCountyareatwillandmayresigntheiremploymentatanytime,althoughatleasttwoweeksnoticeisrequiredfor  paymentofaccruedvacationtime,andmaybeterminatedasprovidedintheKentCountyCode,ordinances,and/orpolicies.  *KentCountyisanequalopportunityemployerandwillnotdiscriminateagainstanyemployeeorapplicantforemploymentinamanner a( thatviolatesthelaw.Accommodationsareavailableforapplicantswithdisabilitiesinallphasesoftheapplicationandemploymentprocess. % ContactthePersonnelOfficeforanauxiliaryaidorservice.  *KentCountymaintainsadrugfreeworkplaceandwillnottoleratetheuse,possessionordistributionofillegalsubstances.Employees q8 mustabidebytheCounty'sdrugfreeworkplacepolicy. 5 *KentCountyrequiresalloffersofemploymenttobeextendedwiththefollowingconditions:theprospectiveemployeemustpassa  criminalbackgroundinvestigationandadrug&alcoholuse/abusescreeningprocedure,followedbya6monthintroductoryperiod. H  *KentCountyrequiresallmaleapplicantsbornafterJanuary1,1960toberegisteredwithSelectiveService.  "   READTHEFOLLOWINGSTATEMENTCAREFULLYBEFORESIGNING: X$   IAFFIRMTHISAPPLICATIONCONTAINSNOMISREPRESENTATIONORFALSIFICATIONSANDTHATTHE !& INFORMATIONGIVENBYMEISTRUEANDCOMPLETETOTHEBESTOFMYKNOWLEDGEANDBELIEF.IAMAWARE !' THATSHOULDINVESTIGATIONATANYTIMEDISCLOSEANYSUCHMISREPRESENTATIONORFALSIFICATION,MY "h( APPLICATIONWILLBEREJECTEDOR,IFEMPLOYEDBYTHECOUNTY,IMAYBETERMINATEDFROMEMPLOYMENT. e#, ) ICERTIFYTHATIFIAMMALE,BORNAFTERJANUARY1,1960,IHAVEREGISTEREDFORSELECTIVESERVICEAND )$ * MAYBEREQUIREDTODOCUMENTREGISTRATION.IUNDERSTANDTHATIMUSTPASSACRIMINALBACKGROUND $!+ INVESTIGATIONANDPASSTESTINGFORALCOHOLANDSUBSTANCEUSE/ABUSE,ASACONDITIONOFEMPLOYMENT. %x", IALSOUNDERSTANDTHATDIRECTDEPOSITOFPAYISACONDITIONOFEMPLOYMENT.IUNDERSTANDTHATIF u&<#- IAMEMPLOYED,IWILLSERVEANINTRODUCTORYPERIODOFPROBATIONOFATLEASTSIX(6)MONTHSAND 9'$. SUBJECTTOTERMINATIONWITHOUTRIGHTOFAPPEAL.IFURTHERAUTHORIZEANYANDALLOFMYCURRENT '$/ ORPREVIOUSEMPLOYERS,ASSOCIATES,ORREFERENCESTOGIVETHEDIRECTOROFPERSONNELORANYCOUNTY (%0 OFFICE/DEPARTMENTANYINFORMATIONCONCERNINGMYEMPLOYMENTRECORDORCHARACTER.FINALLY,I )L&1 AUTHORIZETHATCOPIESOFTHISAPPLICATIONMAYBEFURNISHEDTOINTERESTEDCOUNTY I*'2 OFFICES/DEPARTMENTS.  +'3 ________________________________________________________0  0p%%________________________,\)5p%p% SIGNATUREOFAPPLICANT0 0 % %0h%%0h%h%0%%0p%%0p%p%DATEY- *6%%   sH Page4of5# sHx#&W %   .+8 x #  %&Wx#    KENTCOUNTY,DELAWARE#  Uy#  9 PERSONNELOFFICE M KentCountyAdministrativeComplex,Room213  555BayRoad,Dover,Delaware19901  (302)7442310,Fax(302)7362262 ` www.co.kent.de.us&W %  ]$  @  @` THISPAGEWILLBEDETACHEDFROMTHEAPPLICATIONFORMUPONSUBMISSION  ANDONLYUSEDFORAUTHORIZEDPURPOSES.   #  %&Wz#&W %  AUTHORIZATIONTORELEASEINFORMATION Y  AND 1  CONDUCTCRIMINALBACKGROUNDINVESTIGATION       AsacandidateforapositionintheKentCounty,Delawaregovernment,Iamrequiredtofurnishinformationforusein   determiningmyqualifications.Forthatpurpose,Iauthorizethereleaseofanyandallinformationthatyoumayhave X  concerningme,includinginformationofaconfidentialorprivilegednature. i0 IherebyauthorizetheKentCountygovernment(KentCountyLevyCourt)anditsrepresentativestoconductacriminal  backgroundinvestigationandprovideinformationbelowtoassistinthatinvestigation.IunderstandthatIwillneedtobe  fingerprintedtocompletethisinvestigation.  Iherebyreleaseyou,yourorganization,andothersfromliabilityordamagewhichmayresultfromfurnishingor y@ receivingtheinformationrequested. Q NAME(Printed): ` ____________________________________________________________________________  DATE:     ` ____________________________________________________________________________  #  %&W{#&W % SIGNATURE:   ` ____________________________________________________________________________ P #  %&WO#&W % SOCIALSECURITY#:#  %&W#(Provideonlyafterhireoffermade&accepted.BringoriginalSScardtonewhireorientationmeeting)&W % Ԁ 9 #  %&Wނ#&W % DRIVER'SLICENSE#:____________________________________________________________________________   #  %&W6#&W % STATEISSUED: ` ____________________________________________________________________________ ! #  %&W#&W % BIRTHDATE:   ` ____________________________________________________________________________ " #  %&W#&W % CURRENTADDRESS:____________________________________________________________________________ q!8$ #  %&Wq#&W % PREVIOUSADDRESS:____________________________________________________________________________  #& ̄ $!(   Wearerequiredtokeepinformationonapplicantsex,race,andethnicbackgroundincompliancewithfederal m&4#* law.Thisinformationwillbedetachedandkeptseparatelyfromyourapplication.Itwillnotbeusedasabasisfor E' $+ makingemploymentdecisions.Yourcooperationisgreatlyappreciated. ($, #  %&W'#&W % Position(s)appliedfor:______________________________________________________________________________ )&. YourSocialSecurityNumber:__________________________YourBirthdate:________________YourSex:_________ *l'/ YourRaceorNationalOrigin:(Pleasecheckone)#  %&W # N #  N#&W % HispanicorLatino;#  %&WNJ# N #  N"#&W % White;#  %&Wh# N #  N#&W % BlackorAfricanAmerican; }+D(0 #  %&W# N #  No#&W % NativeHawaiianorOtherPacificIslander;#  %&W# N #  N$#&W % Asian;#  %&Wj# N #  N#&W % AmericanIndianorAlaskaNative;#  %&W# N #  Na#&W % TwoormoreRaces#  %&W#&W %  ,~)1 Areyouhandicapped?_______NoIfYesExplainextentofhandicap:__________________________________ -*2   #  %&W#sH Page5of5# sHۏ#