Fiscal Specialist - Job Opening

2. Application for Employment
4. Summary

   Title: Fiscal Specialist

   Department: Preble County Job and Family Services

   Location: 1500 Park Ave. Eaton, OH 45320

6. Please complete the entire application form.

8. Position Sought:*
10. Name*
11. Email Address*
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Last 4 of your SSN:*
21. Are you an adult?*

    1. Yes
    2. No
23. Employment History and Work Experience

    In this section, list all employment history and work experience in date order. Begin with your current employer. Use additional paper if necessary. Failure to include all employment may be grounds for disqualification.

25. Title of your present or most recent position*
27. Company Name*
28. Phone*
30. Street Address*
31. City*
33. State*
34. Zip Code*
36. From (month and year)*
37. To (month and year)*
39. Name and title of immediate supervisor*
40. Are you employed by this company now?*
    -- Select One --YesNo
42. Beginning Salary*
43. Current Salary*
44. May we contact your current employer prior to employment?*

    1. Yes
    2. No
46. Description of duties*
48. Reason for leaving*
52. Title of your present or most recent position*
54. Company Name*
55. Phone
57. Street Address*
58. City*
60. State*
61. Zip Code*
63. From (month and year)*
64. To (month and year)*
66. Name and title of immediate supervisor*
67. Are you employed by this company now?*
    -- Select One --YesNo
69. Beginning Salary*
70. Current Salary*
72. Description of duties*
74. Reason for leaving*
78. Title of your present or most recent position*
80. Company Name*
81. Phone
83. Street Address*
84. City*
86. State*
87. Zip Code*
89. From (month and year)*
90. To (month and year)*
92. Name and title of immediate supervisor*
93. Are you employed by this company now?*
    -- Select One --YesNo
95. Beginning Salary*
96. Current Salary*
98. Description of duties*
100. Reason for leaving*
104. Title of your present or most recent position*
106. Company Name*
107. Phone
109. Street Address*
110. City*
112. State*
113. Zip Code*
115. From (month and year)*
116. To (month and year)*
118. Name and title of immediate supervisor*
119. Are you employed by this company now?*
     -- Select One --YesNo
121. Beginning Salary*
122. Current Salary*
124. Description of duties*
126. Reason for leaving*
130. Title of your present or most recent position*
132. Company Name*
133. Phone
135. Street Address*
136. City*
138. State*
139. Zip Code*
141. From (month and year)*
142. To (month and year)*
144. Name and title of immediate supervisor*
145. Are you employed by this company now?*
     -- Select One --YesNo
147. Beginning Salary*
148. Current Salary*
150. Description of duties*
152. Reason for leaving*
156. Education and Training

     This section is intended to give the employer information about the education and training that the applicant has completed, and to demonstrate the skills, knowledge, and abilities of the applicant to perform the job duties of the position.

158. High School Attended name and address*
160. Did you graduate?*
     -- Select One --YesNo
161. If no, was a GED received?*
     -- Select One --YesNo
163. Courses Pertaining to Job Applied For*
165. Activities, Awards, Sports, Etc.*
167. College/University/Trade School name and address
169. Did you graduate?

     1. Yes
     2. No
170. Degree or Certificate awarded
172. Courses Pertaining to Job Applied For
174. Activities, Awards, Sports, Etc.
176. Graduate School(s) name and address
178. Major
179. Credit hours earned
181. Graduation date
182. Degree or Certificate awarded
186. Please use the following space to provide any further information on training, education, skills, abilities, hobbies, volunteer work, etc., that you possess or have experienced that may be helpful in the evaluation of your application.
190. Personal Information
192. Do you have any commitments (i.e., second job, school, etc.) which might interfere with, or adversely affect, your employment should we select you for a position?*

     1. Yes
     2. No
193. If yes, please explain
195. Do you possess a valid Drivers License?*

     1. Yes
     2. No
196. If no, can you obtain one prior to employment?

     1. Yes
     2. No
198. Are you a resident of Ohio?*

     1. Yes
     2. No
199. If not, are you willing to become a resident upon employment?

     1. Yes
     2. No
201. Please list three references who are not related to you that you have known at least one year.
203. First Name*
204. Last Name*
206. Phone Number*
208. Address
210. City
211. State
212. Zip Code
214. First Name*
215. Last Name*
217. Phone Number*
219. Address
221. City
222. State
223. Zip Code
225. First Name*
226. Last Name*
228. Phone Number*
230. Address
232. City
233. State
234. Zip Code
238. Please read each of the following paragraphs carefully. Indicate your understanding of, and consent to, the contents and conditions of each paragraph by placing your initials at the end of each paragraph. If you have any questions regarding these paragraphs, contact the employer before initialing the paragraph.

240. I understand and accept that, if I am selected for employment, my employment may be conditioned upon my passing any medical examination that the employer deems necessary to determine whether I can physically perform the essential functions of the position, with reasonable accommodation when necessary. I understand and accept that this may include drug, alcohol or substance abuse testing.

241. Initials:*

243. If employed, I understand and accept that, depending on the department in which I am applying for employment, I may be required to work evening shifts or night shifts, including weekends and be on call and work mandatory overtime hours.

244. Initials:*

246. I understand and accept that if any information required in this application is found to be falsified or intentionally excluded, my application may be disqualified from further consideration. I further understand and accept that if I am employed by the employer, I may be subject to disciplinary action, including termination, if any information required by this application has been falsified or intentionally excluded.

247. Initials:*

249. I understand and accept that the employer requires a high degree of integrity and confidentiality of its employees. I also understand and accept that the various law enforcement and informational agencies that exchange information and data with the employer require that the employer's employees do not have a past record of unlawful activities. Therefore, I understand and accept that, depending on the department in which I am applying for employment, it may be necessary for the employer to investigate my background for any criminal or unlawful activity.

250. Initials:*

252. I hereby authorize the employers, schools and personal references named in this application to provide information regarding me to the employer. I further authorize the release of personnel, academic and other records to the employer.

253. Initials:*
257. Through submitting this application:

     I solemnly swear that all of the information furnished in this employment application is true, accurate, and complete to the best of my knowledge. I authorize investigation of all statements contained in this application. I understand that any misrepresentation or falsification of the information provided may lead to withdrawal of an employment offer or termination following employment. I recognize that my future employment with the employer will be jeopardized if I engage in substance abuse, illegal drug use, or alcohol abuse. I understand that if I am interviewed by the employer for a position, this application will be notarized.

261. This section will be completed in person prior to interview

     PLEASE READ CAREFULLY BEFORE SIGNING

     ***********************************************************

     I agree that any claim or lawsuit relating to my service with the County or any of its departments must be filed no more than six (6) months after the date of the employment action that is subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

     ***********************************************************

263. Applicant Signature
264. Date
266. Notarized by
267. Date
Leave This Blank:


269. 1. Receive an email copy of this form.
270. Email address

     This field is not part of the form submission.

271. Submit Submit and Print

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