Pre-Employment Questionnaire * An Equal Opportunity Employer * Revised 11/24/19
Date Social Security # (Optional) If you reside outside of Hamilton County, are you willing to relocate within the county? Email Phone Fax Are you at least 18 years of age? Are you legally eligible to work in the United States? Present Membership in National Guard or Reserves
Position Date you can start Salary desired If so, may we contact your present employer? If the job requires working weekends and nights, would you be willing to accept it?
(List below last three employers, starting with the last one first.) Employment History Employment History Name and Address of Employer Position/Responsibilities/Salary Employment History (copy) Name and Address of Employer Position/Responsibilities/Salary Employment History (copy) (copy) Name and Address of Employer Position/Responsibilities/Salary Have you previously been employed by Hamilton County? If "Yes", when and which department(s)? Other relevant employment experience?
Layout Name & Location of School Layout (copy) Name & Location of School Layout (copy) (copy) Name & Location of School
Subjects of special study or research work Have you been convicted of a felony or misdemeanor within the last 5 years?**
** You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.
Give the names of three persons not related to you, whom you have known at least one year. References
I understand and agree that I will be required to have a physical examination if offered position:
Hamilton County has a policy of non-discrimination on the basis of disability as provided by the Americans with
Disabilities Act of 1990.
PLEASE READ CAREFULLY BEFORE SIGNING
All applicants for employment are required to submit to a drug and alcohol test after a conditional offer of
employment has been made. The results of the drug and alcohol tests will be provided to the County. If you are
currently using illegal drugs or controlled substances, you are not eligible for employment. If you use illegal
drugs or controlled substances after you have been employed, you will be subject to disciplinary action or
dismissal. This policy does not apply to the use of medications which have been prescribed for an individual by
a licensed medical practitioner and which are used strictly in accordance with the prescription.
"I certify that the statements made by me on this application and all related information which I have provided are
true, accurate, and complete to the best of my knowledge. I understand that if I provide any false, inaccurate, or
incomplete information, I will not be eligible for employment, or, if I am hired, regardless of the date on which the
County discovers the violation of its policy regarding application form dishonesty.”
“In connection with my application for employment with the County, I expressly authorize the release to the
County of any records or information which may refer or relate to my application for employment, including, but
not limited to, records of schools, law enforcement or criminal justice agencies, and previous employers. I
hereby release and discharge the County and any other person, firm, agency or corporation from any and all
claims and liability which I may have or ever claim to have relating to information provided to the County as part
of my application for employment.”
If I am offered and accept employment with the County, I understand that my employment is At Will and that my
employment may be terminated at any time and for any reason either by me or by the County.
Applications will be kept on file in the for one year. Date Signature
BACKGROUND RESEARCH RELEASE Please read this section carefully and acknowledge your understanding by signing your name in the space
I certify that all of the statements made by me on this application for employment are true, correct, and complete to
the best of my knowledge.
1. Consent to Conduct Background Investigation
As a condition of and in consideration for Hamilton County's consideration of this application, I give permission to
Hamilton County to investigate my personal and employment history. I understand that this background investigation
will include, but not be limited to, verification of all information on this application, as well as interviews with past
employers. I further give permission to Hamilton County to conduct this investigation and to discuss the results of this
investigation in connection with my application for employment.
2. Consent to Contact Past Employers
I give permission to Hamilton County to contact all employers listed in this application (except those specifically
excluded) for references. I further give permission to all current or previous employers and/or managers or supervisors
to discuss my relevant personal and employment history with Hamilton County, consent to the release of such
information orally or in writing, and hereby release them from all liability and agree not to sue them for defamation or
other claims based upon any statements they make to any representative of Hamilton County. I further agree to
indemnify all past employers for any liability they may incur because of their reliance upon this release.
3. Consent to Contact Government Agencies
I give permission to any agent, attorney or representative of Hamilton County to receive a copy of any information
obtained in the file of any federal, state or local court, governmental agency, law enforcement agency or investigator
concerning or relating to me. I understand that the scope of this investigation will be limited to criminal and/or civil
records that relate to my honesty, integrity and/or abilities.
4. Cooperation With Investigation
I agree to fully cooperate in Hamilton County's background investigation, and to sign any waivers or releases that may
be necessary to obtain access to relevant information. In the event that any former employer or federal, state or local
government agency will not release reference information or criminal history information directly to the employer, I
agree to personally request such information to the extent permitted by law.
5. Falsification Statement
I understand that any falsification or willful omission of fact made in this application or in connection with any
background investigation may result in rejection of this application, or, if discovered after an offer of employment, in
6. Employment "At Will"
In consideration of my employment, I agree to conform to the rules and regulations of Hamilton County, and MY
EMPL0YMENT AND COMPENSATION IS "AT WILL " IN THAT THEY CAN BE TERMINATED WITH OR WITHOUT
CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF EITHER HAMILTON COUNTY
OR MYSELF. Applicant's Signature Company Representative/Job Title Date