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Summary
La Porte County is an Equal Employment Opportunity Employer. Applicants are considered for employment without regard to race, religion, color, national origin, sex, age, disability, veteran status, genetic information, or any other basis prohibited by law.
Personal Info
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home/Cell*
Secondary Phone
Email Address*

WORK HISTORY
Provide employment information for the PAST TEN (10) YEARS. List your employment history beginning with the most recent. Include full or part-time, Military, summer jobs, etc.
Employer 1
Name of Employer/Company*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone*
Job Title/Position*
Supervisor Name and Title*
Supervisor Contact Number*
Start Date
Month
Day
Year
End Date
Month
Day
Year
Starting Salary/Hourly Rate
Please enter a number from 0 to 100000.
Ending Salary/Hourly Rate
Please enter a number from 0 to 100000.
Previous Position
Reason For Leaving
Duties/Responsibilities
Add Another Employer?
Employer 2
Name of Employer/Company*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone*
Job Title/Position*
Supervisor Name and Title*
Supervisor Contact Number*
Start Date
Month
Day
Year
End Date
Month
Day
Year
Starting Salary/Hourly Rate
Please enter a number from 0 to 100000.
Ending Salary/Hourly Rate
Please enter a number from 0 to 100000.
Previous Position
Reason For Leaving
Duties/Responsibilities
Add Another Employer?
Employer 3
Name of Employer/Company*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone*
Job Title/Position*
Supervisor Name and Title*
Supervisor Contact Number*
Start Date
Month
Day
Year
End Date
Month
Day
Year
Starting Salary/Hourly Rate
Please enter a number from 0 to 100000.
Ending Salary/Hourly Rate
Please enter a number from 0 to 100000.
Previous Position
Reason For Leaving
Duties/Responsibilities
Add Another Employer?
Employer 4
Name of Employer/Company*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone*
Job Title/Position*
Supervisor Name and Title*
Supervisor Contact Number*
Start Date
Month
Day
Year
End Date
Month
Day
Year
Starting Salary/Hourly Rate
Please enter a number from 0 to 100000.
Ending Salary/Hourly Rate
Please enter a number from 0 to 100000.
Previous Position
Reason For Leaving
Duties/Responsibilities
Add Another Employer?
Employer 5
Name of Employer/Company*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone*
Job Title/Position*
Supervisor Name and Title*
Supervisor Contact Number*
Start Date
Month
Day
Year
End Date
Month
Day
Year
Starting Salary/Hourly Rate
Please enter a number from 0 to 100000.
Ending Salary/Hourly Rate
Please enter a number from 0 to 100000.
Previous Position
Reason For Leaving
Duties/Responsibilities
Add Another Employer?
Employer 6
Name of Employer/Company*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone*
Job Title/Position*
Supervisor Name and Title*
Supervisor Contact Number*
Start Date
Month
Day
Year
Starting Salary/Hourly Rate
Please enter a number from 0 to 100000.
Ending Salary/Hourly Rate
Please enter a number from 0 to 100000.
Previous Position
Reason For Leaving
Duties/Responsibilities
Add Another Employer?
Employer 7
Name of Employer/Company*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone*
Job Title/Position*
Supervisor Name and Title*
Supervisor Contact Number*
Start Date
Month
Day
Year
End Date
Month
Day
Year
Starting Salary/Hourly Rate
Please enter a number from 0 to 100000.
Ending Salary/Hourly Rate
Please enter a number from 0 to 100000.
Previous Position
Reason For Leaving
Duties/Responsibilities
Add Another Employer?
Employer 8
Name of Employer/Company*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone*
Job Title/Position*
Supervisor Name and Title*
Supervisor Contact Number*
Start Date
Month
Day
Year
End Date
Month
Day
Year
Starting Salary/Hourly Rate
Please enter a number from 0 to 100000.
Ending Salary/Hourly Rate
Please enter a number from 0 to 100000.
Previous Position
Reason For Leaving
Duties/Responsibilities

REFERENCES
List 3 persons who are NOT RELATED TO YOU and who would have knowledge of your qualifications for the position(s) for which you are applying, such as former co-workers, teachers, etc. DO NOT repeat the names of supervisors listed under experience.
Reference 1
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Occupation*
Reference 2
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Occupation*
Reference 3
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Occupation*
Attach Your Resume
Accepted file types: pdf, jpg, jpeg, png, gif, doc, docx, Max. file size: 48 MB.
Military Service
Have you ever served in the Armed Forces?
If yes, which Branch of Service?
Period of Duty Started
Month
Day
Year
Period of Duty Ended
Month
Day
Year
Date of Final Discharge
Month
Day
Year
Rank at Discharge
Criminal History
Have you ever been convicted of a Felony?*
If yes, please list the following information for each offense (Conviction type, Date, Location, and Offense)*

ACKNOWLEDGMENT AND AUTHORIZATION TO RELEASE INFORMATION
I certify that answers given herein are true and complete to the best of my knowledge. I authorize La Porte County Government and its designated representatives to conduct an appropriate background investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision and authorize any person who may have information relative to this investigation to disclose same. I also release any person from any form of liability for such disclosure. As part of the County's procedure for processing your employment application, a background investigation will be conducted and your personal and employment references may be checked. Any Credit Bureau, Retain Merchants Association, Banks, Financial Institution, or Credit Extending Organization. Any Department of a city, county, state or Federal Government, or its agency. Any Doctor, Hospital or medical clinic. Any Principal, Dean, Counselor or authorized person at a College, University, School, Trade School or learning institution. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. In the event of employment, I understand that false or misleading information given in this application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the US, have a physical examination and/or drug test, or sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above:*
I certify that answers given herein are true and complete to the best of my knowledge.

I authorize La Porte County Government and its designated representatives to conduct an appropriate background investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision and authorize any person who may have information relative to this investigation to disclose same. I also release any person from any form of liability for such disclosure.

As part of the County's procedure for processing your employment application, a background investigation will be conducted and your personal and employment references may be checked. Any Credit Bureau, Retain Merchants Association, Banks, Financial Institution, or Credit Extending Organization. Any Department of a city, county, state or Federal Government, or its agency. Any Doctor, Hospital or medical clinic. Any Principal, Dean, Counselor or authorized person at a College, University, School, Trade School or learning institution. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job.

In the event of employment, I understand that false or misleading information given in this application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the US, have a physical examination and/or drug test, or sign a conflict of interest agreement and abide by its terms.

I understand and agree to the information shown above:

I understand and agree to the information shown above *
Digital Signature*

Digital signature is your full name spelled out followed by the last 4 of your SSN
Date*
Month
Day
Year
DIVERSITY INFORMATION
This employer has requested Equal Employment Opportunity/Affirmative Action (EEO/AA) demographic information as part of their application process. Providing this information is strictly voluntary. Select 'Decline to Identify' if you do not wish to provide it. The law prohibits employers from taking any adverse action against you if you choose not to provide this information.*
Ethnicity Information
Ethnicity
Hispanic or Latino a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race.

White (not Hispanic or Latino) a person having origins in any of the original people of Europe, the Middle East, or North Africa.

Black or African American (not Hispanic or Latino) a person having origins in any of the black racial groups of Africa Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) a person having origins in any of the original People of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (not Hispanic or Latino) a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Native American (not Hispanic or Latino) a person having origins in any of the original peoples of North or South America (including Central America), and who maintains tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino) all persons who identify with more than one of the above races.
Gender
Name
This field is for validation purposes and should be left unchanged.

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Application

Step 1 of 7

Summary

Personal Info

APPLICATION FOR EMPLOYMENT

Employment Desired

Education & Training

HIGHER EDUCATION

College/University

Graduate/Professional School

Vocational School/Other

LICENSE/REGISTRATION/CERTIFICATE

SPECIALIZED SKILLS & KNOWLEDGE

WORK HISTORY

Employer 1

Employer 2

Employer 3

Employer 4

Employer 5

Employer 6

Employer 7

Employer 8

REFERENCES

Reference 1

Reference 2

Reference 3

Military Service

Criminal History

ACKNOWLEDGMENT AND AUTHORIZATION TO RELEASE INFORMATION

DIVERSITY INFORMATION

Ethnicity Information

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