Application Date:

Mailing Address:

City, State, Zip Code:

Email:

Are you a U.S. Citizen or, if not, do you have a legal right to work in this country?
Yes   No

Can you provide, after employment, birth certificate or other proof of citizenship?
Yes   No

List any special skills, knowledge, language, equipment operated, etc.

Do you have any relatives working for York County Government?
Yes   No
If Yes, who?

Where are they employed?

 

Full Name (Last, First, Middle):

Social Security Number:

Home Phone:

Work Phone:

Have you ever applied for a position with York County?
Yes   No
If Yes, when and where?

Have you ever been convicted of a felony?
Yes   No
If yes, give details; Exclude minor traffic violations. (A conviction in and of itself may not be a bar to employment.)

Type of employment desired:
Full-Time   Part-Time   Temporary

Date available for work?

Do you have a valid driver's license?
Yes   No

Applications for employment are filed according to the position applied for, therefore, be as specific as possible in stating the position desired.
-- Select -- Communications Specialist (Full-Time) Communications Specialist (Part-Time) GIS Analyst Lead Training Supervisor

G.E.D.?
Yes   No

High School:

High School Name/Location:

Degree Earned or Credit Hrs.:

Major/Vocation:

Grade Average:

College:

College Name/Location:

Degree Earned or Credit Hrs.:

Major/Vocation:

Grade Average:

Select highest grade completed:

Elementary/High School:

College:

Graduate School:

Graduate School:

Graduate School Name/Location:

Degree Earned or Credit Hrs.:

Major/Vocation:

Grade Average:

 

Special Course 3:

Dates Enrolled:
From:   To:
School or other sponsor of course:

Describe Major Content of Course:

Special Course 5:

Dates Enrolled:
From:   To:
School or other sponsor of course:

Describe Major Content of Course:

Special Course 4:

Dates Enrolled:
From:   To:
School or other sponsor of course:

Describe Major Content of Course:

3.
Name & Address of Employer:

Supervisor's Name, Title & Phone #:

Job Title and/or description of duties:

Dates Employed:
From:   To:
Hourly Rate:
Start:   Finish:
Reason for leaving:

5.
Name & Address of Employer:

Supervisor's Name, Title & Phone #:

Job Title and/or description of duties:

Dates Employed:
From:   To:
Hourly Rate:
Start:   Finish:
Reason for leaving:

So we may accurately track our efforts in the area of equal employment opportunity, we request that you fill out the Applicant Data Record.  Completion of this record is voluntary.  This data will be kept in a confidential file separate from the Application for Employment and will in no way affect consideration for employment with our company.

Applicant:	Date:
Position Applied for:	Department:

Sex:
Male
Female

Referral Source:
Direct write in
Newspaper ad
Private Employment Agency
College Recruiting
State Employment Office
Walk-in
School Referral
Employee Referral
      Employee's Name:
Other, Specify:

Type of Position Applied For:
Officials/Managers
Professionals
Technicians
Clerical
Craft (Skilled)
Operatives (Semi-Skilled)
Laborers (Unskilled)
Service Worker

Disabled Veteran:
No
Yes (Entitled to disability compensation under law administered by Veteran's Administration for disability rate 30% or more or discharged/released from active duty for disability incurred or aggravated in the line of duty.)

Special Disabled Veteran:
No
Yes (Discharged/released from active duty because of service-connected disability or entitled to disability compensation (or who, but for receipt of military retired pay, would be entitled to disability compensation) for a disability (i) rated at 30% or more, or (ii) rated at 10% or 20% and under 38 U.S.C. 1506 has been determined to have a serious employment handicap.)

Handicapped:
No
Yes (Have a physical or mental impairment which substantially limits a major life activity or have a history of such impairment.)

Why did you apply at York County?

What are your strengths?

Desired salary?

When can you start?

What do you look for in a job?

What are your weaknesses?

What are your goals?

COUNTY OF YORK
PUBLIC SAFETY DISPATCHER
CHECKLIST

(Please skip this section if you are applying for a position other than dispatcher)

Experience has shown that many applicants for positions consider only the positive aspects of the job while ignoring some of its less attractive features.  As a result, when new employees encounter negative job features they sometimes react by leaving the job well before training is completed (sometimes in only a few weeks).  Early resignations, which result from lack of accurate job knowledge, contribute to a much higher than desirable attrition rate among trainees.

There are many satisfying, rewarding aspects to the position.  The job offers the opportunity to make significant contributions to the welfare and safety of the public and fellow employees.  The work is challenging and rewarding.  It is important for all applicants to carefully consider both the negative and positive features of a new career before deciding to test for the position.

The job factors listed below are features of the position about which many applicants are unaware.  If any of these conditions are unacceptable to you, we strongly suggest you consider alternative employment choices which may better fit your individual needs.

Place a check on the line following the statement to indicate you have read and thought about each item.

Working Environment

Work Schedule

Call Types

Hours of Work

I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I understand that any false answers or statements made by me on this application or in any supplemental information given during the County’s pre-employment investigations or physical examination will be cause for immediate discharge. I agree that The County of York shall not be liable in any respect if my employment is terminated because of falsification of any statements or omissions made by me in this questionnaire or attachments. I hereby authorize the companies, schools, or persons named in this questionnaire to give any pertinent information to The County of York and I release said parties from all liability for any damage for issuing such information.

I consent to taking a pre-employment job-related physical examination and such job-related physical examinations in the future as may be required by The County of York.

I acknowledge that my employment may be terminated, and any offer of employment, if such is made, may be withdrawn, with or without cause and with or without prior notice, at any time, at the option of The County of York or myself. I understand that no representative of the County of York has any authority to enter into any agreement for employment for any specified period of time, or to assure or make some other personnel move either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing.

Signature (type full name):
    Date: