Employment Application

Position(s) Applying for:*

Full Time Telecommunicator

Part Time Telecommunicator

Applicant Information

First Name*

Middle Initial

Last Name*

Street Address*

Apartment/Unit #

City*

State*

Zip*

Phone*

Email Address*

Date of Birth

Place of Birth (City, County and State)

IL FOID #

Social Security #

IL Driver's License #

Are you a citizen of the United States?*

Yes

If no, are you authorized to work in the U.S.?*

Yes

Have you ever worked for this office?*

Yes

If so, when?*

Are you related to anyone at this office?*

Yes

If yes, who?*

Do you have a valid driver's license?*

Yes

Have you ever used a different name?*

Yes

If yes, what was the name?*

Education

High School

Address

From

Did you graduate?

Yes

Degree

College

Address

From

Did you graduate?

Yes

Degree

Other

Address

From

Did you graduate?

Yes

Degree

References

Please list three professional references.

Full Name*

Relationship*

Phone*

Full Name*

Relationship*

Phone*

Full Name*

Relationship*

Phone*

Addresses

In the space provided below, please list your last five addresses. Provide how long you lived at each address in the correct space. Provide your addresses starting with your "most current" address. Remember to provide apartment numbers when applicable and to be as accurate as possible.

Address*

City, State and Zip*

How long did you reside at this address?*

Address

City, State and Zip

How long did you reside at this address?

Address

City, State and Zip

How long did you reside at this address?

Social Networking

Disclose up to six social networking sites that you currently have active profiles (i.e., Facebook, Myspace, Twitter, etc.) Failure to disclose these sites will result in your application being discarded. The Macomb-McDonough County Communications Center may ask potential employees to provide content displayed on social networking sites. Please provide web addresses along with screen names.

Social Networking Site #1

Social Networking Site #2

Social Networking Site #3

Social Networking Site #4

Social Networking Site #5

Social Networking Site #6

Legal Questions

Have you ever been convicted of a felony?*

Yes

Have you ever been convicted, or plead guilty to a Misdemeanor or Traffic Violation?*

Yes

If yes, please provide county, city and state plus date of offense.*

Have you ever been the Defendant in a civil suit?*

Yes

If yes, please provide county, city and state.*

Previous Employment

List your past three employers, starting with the most current.

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Company

Phone

Address

Supervisor

Job Title

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Military Service

Branch

From

Rank at Discharge

Type of Discharge

Permanent Duty Station

Are you currently in the Active Reserve?*

Yes

Have you ever been the subject of any judicial or non-judicial disciplinary action while in the military?*

Yes

Disclaimer and Signature

READ CAREFULLY BEFORE PROVIDING YOUR SIGNATURE BELOW

I do hereby affirm and certify that all answers and information given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained within this application for employment as may be necessary in arriving to an employment decision. In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge, dismissal or penalty under law. I further understand that I am required to abide by all rules and regulations of the employer.

I have submitted or will submit to fingerprinting as required. I agree to submit to a Polygraph Examination (lie detector), Psychological Examination, and Background Investigation. I authorize any of my references, employers, or schools to furnish information requested by the Macomb-McDonough County Communications Center to be released to the Macomb-McDonough County Communications Center.

I understand that employment may be conditional upon successfully passing a screening process that may include a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment. My refusal to take a drug screening will result in no further consideration for employment.

Signature

Date

What is 2 + 2?*

Just making sure you are a human and not a robot.