APPLICATION FOR EMPLOYMENT

420 Mt. Rushmore Rd Custer, SD 57730
Phone: (605) 673-8175 Fax: (605) 673-8153

INSTRUCTIONS: All job applicants must complete the following form before being employed. Please print in ink or type all answers. Photocopies are acceptable. Please sign and date application. You are welcome to attach a resume.

“Equal Opportunity Employer”
It is the policy of Custer County to affirmatively recruit, hire, train and promote the most qualified persons into all job levels without regard to race, color, religion, national origin, sex, or disability, and to recruit for disabled veterans, and veterans of the Vietnam Era.

AMERICANS WITH DISABILITIES ACT COMPLIANCE: Custer County fully subscribes to the provisions of the Americans with Disabilities Act and will attempt in its employment process to make any reasonable accommodations necessary to assist qualified person with disabilities.

I understand that nothing in this application is intended to imply or create an employment relationship or contract for employment. I further understand that, if hired, my employment is at-will and can be terminated at any time, with or without notice, for any reason. I also understand that, while personnel policies, programs, and procedures may change from time to time, such at-will status is not subject to change without a written agreement signed by an authorized representative of Custer County.

 	PERSONAL 	
Please print 
Position Applied For:	 	

-	-
Last Name	First		MI		Social Security Number Current Street Address		City		State	Zip
Phone: Home (	)		Work (	)	Cell (	) 	 Email address
Are you legally authorized to work in the United States? Yes	No

If the position requires driving, do you have a valid driver’s license? Yes	No If yes, please list your driver’s license number. State:	Number:

If the position requires a commercial driver’s license, do you have a commercial driver’s license? Yes	No Class: A	B	C	Endorsements:

In accordance with the Federal Department of Transportation and the policy of Custer County, the County conducts urine drug screening for pre-employment and at prescribed times for safety-sensitive positions. If you refuse testing or test positive (evidence of drug usage), your offer of employment will be withdrawn. Custer County also complies with the Drug-Free Workplace Act of 1988.

Are you requesting veteran preference? Yes	No

 	EDUCATION AND TRAINING 	

Do you have a high school diploma or GED? Yes	No

Please check the highest year of education completed:
8	9	10	11	12	13	14	15	16	17	18	19	20

Please list high school, college or vocational institution attended.
Name/Address	Major	Degree	

			

Please list any other training, skills and abilities that may be applicable to this position:

Please list any equipment or machinery you are trained and qualified to operate:

Please list any license or certificates you may have that may be applicable to your consideration for this position:

 	WORK HISTORY 	

Have you ever worked for Custer County? Yes	No	If yes, please state last position held and period of employment.	
Position Title:		From	/	(mo/yr) To	/	(mo/yr).	

Start with your present or most recent employment. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disability or other protected status.

May we contact your present or most recent employer regarding your qualifications? Yes	No

INSTRUCTIONS: All job applicants must complete the following. Please print in ink or type all answers. Photocopies are acceptable. Please sign and date application. You are welcome to attach a resume.

1.

Job Title				Starting Salary			Last        Salary 		 Dates of Employment: From    /	(mo/yr) To  /		(mo/yr)             Total Years			Months  	        Employer					Phone (	)	-
Employer’s Address Supervisor’s Name and Title
Contact Person	Phone (	)	-	Email Reason for Leaving
Complete description of duties:

2.

Job Title				Starting Salary			Last        Salary 		 Dates of Employment: From    /	(mo/yr) To  /		(mo/yr)             Total Years			Months  	        Employer					Phone (	)	-
Employer’s Address Supervisor’s Name and Title
Contact Person	Phone (	)	-	Email Reason for Leaving
Complete description of duties:

You may attach additional sheets as needed.

Name

Address 	

City				State	Zip    	 Phone:  (	)	-	(daytime               hours)	Email: 		

Name

Address 						 City				State	Zip    	 Phone:  (	)	-	(daytime               hours)	Email: 		

Name

Address 						 City				State	Zip    	 Phone:  (	)	-	(daytime               hours)	Email: 		

Are you at least age 18? Yes	No	If no, what is your age?

BACKGROUND INFORMATION: Custer County conducts background checks for all employees. If you are 18 years of age or older, or are under 18 but have been convicted of a crime in adult court, please complete this section.

Have you been convicted in a court of law? Yes	No

List below any violations, other than minor traffic offenses, for which you were convicted. One or more convictions will not necessarily disqualify you from employment with Custer County. The decision will be based on a number of factors such as the duties of the job for which you are being considered, the seriousness of the offense of which you were convicted, your age at the time of the offense, rehabilitation efforts, the recency of the offense, etc. Please be complete. All information is subject to verification. Failure to disclose convictions may result in disqualification.

OFFENSE	PLACE	DATE	DISPOSITION (Sentence)

AUTHORIZATION FOR RELEASE OF INFORMATION
As a part of the Custer County employment process, we may be checking your background relative to job and personal references, criminal record, and social services record. In order to do that, we must have your authorization.
The undersigned hereby authorizes any state department of social services, any police department, and the Custer County Human Resources Department, to obtain and/or release any and all information regarding the social services, work, credit, DOT mandated drug/alcohol testing if applicable, or criminal history of the undersigned applicant for consideration for employment by Custer County. The undersigned also understands that misrepresentation or omission of facts called for in this application is cause for cancellation of the application and/or separation from employment.

Applicant Signature	Date