• general

Employment Form

Positions Applied For
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First Name(*)
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Middle Name
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Last Name(*)
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Address
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City
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State
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Zip
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Telephone(*)
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Cell
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Email(*)
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Shift Applying For
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Date Available for Work(*)
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Are you at least 18 years of age?(*)
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Have you previously worked for Merrimack County ?(*)
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Are you legally eligible for employment in this country?(*)
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(Proof of U.S. citizenship or immigration status will be required upon employment.)
Type of employment desired
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Other
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Have you been convicted of a crime that has not been annulled by the court?
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(Such conviction may be relevant, but does not automatically bar you from employment. Each case is considered on it’s individual merits.)
If yes, give date, location, and nature of crime
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Indicate whether conviction was a misdemeanor or a felony
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Have you ever been “convicted” of abusing, neglecting, or mistreating individuals?
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If yes, please explain.
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How did you hear about Merrimack County?
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EMPLOYMENT HISTORY List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience.
Employer #1
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Telephone
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Address
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Job Title
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Immediate Supervisor and title
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From / To
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Summarize the nature of work performed and job responsibilities
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Reason for leaving
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Hourly rate/salary
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Employer #2
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Telephone
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Address
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Job Title
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Immediate Supervisor and title
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From / To
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Summarize the nature of work performed and job responsibilities
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Reason for leaving
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Hourly rate/salary
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Employer #3
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Telephone
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Address
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Job Title
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Immediate Supervisor and title
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From / To
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Summarize the nature of work performed and job responsibilities
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Reason for leaving
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Hourly rate/salary
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Employer #4
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Telephone
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Address
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Job Title
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Immediate Supervisor and title
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From / To
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Summarize the nature of work performed and job responsibilities
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Reason for leaving
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Hourly rate/salary
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SKILLS AND QUALIFICATIONS Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our Company.
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EDUCATIONAL BACKGROUND
High School
Name and Location
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Years Completed
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Did You Graduate?
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Course of Study
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College
Name and Location
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Years Completed
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Did You Graduate?
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Course of Study
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Other
Name and Location
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Years Completed
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Did You Graduate?
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Course of Study
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References
Reference #1 Name
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Telephone
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Years known
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Reference #2 Name
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Telephone
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Years known
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Reference #3 Name
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Telephone
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Years known
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Type Your Signature(*)
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Please attach your resume, either .PDF or .DOC file
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Addtional document
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Addtional document
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NOTE: Max file size 5 MB.

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