Kewaunee County | Government

Job Applied for:

First Name:

Middle Initial:

Last Name:

If known by any other names, please list them here:

Street Address:

City, State, Zip Code:

Phone Number:

If you are under age 18, can you provide proof of eligibility to legally work?

Are you allowed to lawfully work in the United States through citizenship or eligible immigration status?

Have you applied with Kewaunee County before? If so, please provide the approximate date(s) and position(s) to the best of your recollection:

Arrest and conviction record are considered by Kewaunee County only as allowed by applicable law. Have you been convicted, pleaded guilty, or pleaded no contest in a criminal matter?

If yes, please provide the year(s) and state(s) in which the criminal act occurred below. Attach an additional page if needed.:

If you have any charges pending (other than non-criminal traffic offenses) please provide the state and nature of the charge(s):

If selected, how much notice would need to be provided to your current employer?

EDUCATION:
Do you hold a high school diploma or equivalent?

Please provide information on post-high-school education below:
Name and State of Institution:

Degree/Diploma/Credential:

Completion Status:

Name and State of Institution:

Degree/Diploma/Credential:

Completion Status:

Name and State of Institution:

Degree/Diploma/Credential:

Completion Status:

Name and State of Institution:

Degree/Diploma/Credential:

Completion Status:

Skills and Qualifications: Please share any licenses, skills, training, awards, experiences, etc. that strengthen your qualifications for the position.:

EMPLOYMENT HISTORY: Please include military service, if any. List employment beginning with the most recent position.
Present Or Most Recent Position
Employer:

Address:

From:

To:

Position Title:

Typical work and duties:

Supervisor:

Supervisor Phone:

Supervisor Email:

Salary:

Reason for Leaving:

May Kewaunee County contact this employer?

	Yes
	No

Previous Position 1
Employer:

Address:

From:

To:

Position Title:

Typical work and duties:

Supervisor:

Supervisor Phone:

Supervisor Email:

Salary:

Reason for Leaving:

May Kewaunee County contact this employer?

	Yes
	No

Previous Position 2
Employer:

Address:

From:

To:

Position Title:

Typical work and duties:

Supervisor:

Supervisor Phone:

Supervisor Email:

Salary:

Reason for Leaving:

May Kewaunee County contact this employer?

	Yes
	No

Previous Position 3
Employer:

Address:

From:

To:

Position Title:

Typical work and duties:

Supervisor:

Supervisor Phone:

Supervisor Email:

Salary:

Reason for Leaving:

May Kewaunee County contact this employer?

	Yes
	No

Have you been fired, discharged, asked to resign, or permanently laid off?

If yes, please explain:

References:
Name/Title Address Phone:

Name/Title Address Phone:

Nepotism Policy Statement:

The employment of immediate family members in a supervisor-subordinate relationship may cause serious conflicts and problems with favoritism and employee morale. In addition to claims of partiality in treatment at work, personal conflicts from outside the work environment can be carried into day to day working relationships.

No person shall be employed, promoted, or transferred to any department or agency of Kewaunee County when the employment, promotion, or transfer would result in a supervisor-subordinate relationship between immediate family members. Immediate family is defined as wife, husband, father, step- father, mother, step-mother, guardian, sister, step-sister, brother, step-brother, child, step-child, aunt, uncle, grandchild, grandparent, father-in-law, mother-in-law, sister-in-law, or brother-in-law.

Are you related to any current Kewaunee County employees?

	Yes
	No

If so, please provide their name and your relationship to them below:

Certification of Accurate Application:
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired.

To the extent allowed by any applicable laws, I authorize the verification of any and all information listed in this application by any person, company, school, agency, unit of government, or other entity that I have listed on this application. I authorize any of these entities or individuals to disclose information relevant to my potential employment with Kewaunee County, unless I have explicitly stated Kewaunee County is not to contact the entity, such as a past employer. I hereby forever release, discharge and covenant not to sue any person or organization for any result of providing, obtaining, or acting upon such information. I understand that such information is sought with confidentiality and will not be released to me in any form whatsoever.

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

I further understand that I may be asked to undergo a physical examination, including substance use screening, prior to an appointment to a position with Kewaunee County. Refusal to participate in such screening will result in the rejection of my application.
Typing my signature to the right indicates that I have read, understood, and agree to these terms:

Date:

First Name:

Middle Initial:

Date of Birth:

Dept:

Today's Date:

Racial/Ethnic Identification: Please select the field below that most accurately describes your racial/ethnic identity.:

	White, not of Hispanic Origin- persons having origins in any of the original peoples of Europe, North Africa, or the Middle East
	Black, not of Hispanic Origin- persons having origins in any of the Black racial groups of Africa
	Hispanic- persons of Mexican, Puerto Rican, Cuban, Central or South American, or Spanish culture or origin, regardless of race.
	Asian or Pacific Islander- persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or Pacific Islands.
	American Indian or Alaska Native- persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation
	Decline to Answer

Gender: Please choose the field that best describes your gender identity.:

	Male
	Female
	Decline to Answer

* How did you hear about this position?:

	Kewaunee County Newspaper
	Green Bay Press Gazette
	Kewaunee County Website
	Indeed Job Board
	Job Center of Wisconsin
	Friend
	Relative
	WILENET
	Wisconsin TechConnect
	Wisconsin Counties Association
	Other

* Required Field

Employment

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