BG Employment Application

Chemung County Buildings and Grounds Department

217 Madison Avenue Elmira, NY 14901 607-737-2843
Position(s) Applied for
Today's Date

MonthDayYear
This application must be filled out completely and carefully. Additional Information, including a resume, although not required may be attached.

Chemung County is an Equal Opportunity Employer
Name

First NameMiddle InitialLast Name
Social Security Number
License #
Local Address

Street Address

Street Address Line 2

CityState

Zip Code
School Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Are you under 18 years of age:

YesNo
if yes, or minimum or maximum age limits are established for the position, enter your date of birth here.

MonthDayYear
If you are under the age of 18, you must provide your original working papers prior to employment.
Provide the city, village or town, county and state of which you are an actual permanent legal resident and indicate how long, you have been residing there continually, up to and including the date of this application

School District:

County of:

CityTown/Village ofState of:

Postal / Zip Code
Number of Years
Number of Months
Please check the appropriate box to the right of each question

if you answer yes to any of the following questions, you may give specifics by attaching an addition sheet to this application. If you elect not to provide specifics, however, or if such explanation is insufficient, you may be required to submit further information. None of the following circumstances represent an automatic bar to responsibilities of the position(s) for which you are applying.
Were you ever dismissed or discharged from any employment for reason other than lack of work or funds

YesNo
Did you ever resign from any employment rather than face dismissal?

YesNo
Did you ever receive a discharge from the Armed Forces of the United States which was other than "Honorable" or was issued under other than honorable circumstances?

YesNo
Have you ever been convicted of a crime (felony or misdemeanor)?

YesNo
Have you ever forfeited bail bond posted to guarantee your appearance in court to answer to any criminal charges?

YesNo
Are you now under charges for any crime (felony or misdemeanor)?

YesNo
Work Experience

List most recent position first. If you have no work experience please list three personal reference which are not relatives. This Section must be completed including full addresses and phone numbers.
Employer/Reference 1
Employer/Reference Name
Employer/Reference Address
City/State/Zip
Phone
Date of employment: from-

MonthDayYear
Date
to

MonthDayYear
Date
Position & Duties(include reason for leaving)

0/217
Supervisor:
Employer/Reference 2
Employer/Reference Name
Employer/Reference Address
City/State/Zip
Phone
Date of employment: from-

MonthDayYear
Date
to

MonthDayYear
Date
Position & Duties(include reason for leaving)

0/217
Supervisor:
Employer/Reference 3
Employer/Reference Name
Employer/Reference Address
City/State/Zip
Phone
Date of employment: from-

MonthDayYear
Date
to

MonthDayYear
Date
Position & Duties(include reason for leaving)

0/217
Supervisor:
may we contact the employers, or references, listed above?

YesNo
Signature

Clear
Date

MonthDayYear
Date
Education
Highschool
School
Last Full Year Completed

9101112
Major
College
School
Last Full Year Completed

1234
Major
Other
School
Last Full Year Completed

1234
Major
THIS SECTION MUST BE COMPLETED IF APPLYING FOR A LIFEGUARD POSTION. APPLICANTS MUST BE AT LEAST 16 YEARS OF AGE BY MAY 31ST, AND HAVE CPR FOR THE PROFESSIONAL RESCUER, FIRST AID, AND LIFEGUARD CERTIFICATION
1. I will be able to begin work on Date and can continue service until Date .
2. Have you worked for Chemung County Before Yes No If yes, when ? Where?
3. What special swimming, boating or diving skills can you teach?
4. What age group do you prefer to work with? 4-5 years 6-7 years 8-9 years 10-12 years
5. Rank in order of preference Harris Hill Pool Park Station Waterfront

What certifications do you have?

	Have	Type	Date Issued
Lifeguarding
First Aid
CPR for Professionals
Water Safety Instructors
Small Craft
HaOther

Please provide copies of your certifications with your application.
I, Your name , declare subject to the penalties of perjury, that the statements made in this application have been examined by me and to the best of my knowledge and belief are true and correct. I understand that any omission or misstatement of material facts on this application or any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed.

I further authorize the release of any and all information about myself from any source deemed necessary prior to being considered for appointments within Chemung County. This release may include all or any one of the following: former employers, listed references, central State Registry for Child Abuse and Neglect, Chemung County Department of Social Services, Chemung County Sheriff's Department, the New York State Sex Offender Registry, the National Sex Offender Registry, the National Sex Offender Registry, the Elmira Police Department, New York State Police, and any police agency from areas of former residence, I understand that a background Investigation may be made and the investigation will cover possible civil and criminal cases in which I may have been involved. Only relevant information obtained through this investigation shall be considered for employment purposes.
Signature

Clear
Date

MonthDayYear
Date
Upload any Relevant documents here

Cancelof
County of Chemung

Pre-Employment Background Information Form
Disclosure Regarding Consumer Reports

In connection with your employment offer, including contracts for services, Chemung County may procure a consumer report from a consumer-reporting agency. Such Information can include a credit report, criminal records, driving records, education records, and other information available from public sources

Such a consumer report will be obtained solely for employment purposes

This disclosure is being made in compliance with the Fair Credit Reporting Act (15 U.S.C ss1681-1681u) and New York State Article 23-A Requirements
Your Name:
Street Address:
City,State,Zip:
Social Security Number
DOB

MonthDayYear
Date
Drivers License #:
State:
Other Names Used:
AUTHORIZATION BY EMPLOYMENT CANDIDATE

I hereby authorize Chemung County to produce a consumer report as described above or as permitted by the Fair Credit Reporting Act.
Signature

Clear
Date

MonthDayYear
Date
please Print/save the PDF before submitting this document
Should be Empty:

Chemung County Buildings and Grounds Department

This application must be filled out completely and carefully. Additional Information, including a resume, although not required may be attached.

If you are under the age of 18, you must provide your original working papers prior to employment.

Please check the appropriate box to the right of each question

Work Experience

Employer/Reference 1

Employer/Reference 2

Employer/Reference 3

Education

Highschool

College

Other

THIS SECTION MUST BE COMPLETED IF APPLYING FOR A LIFEGUARD POSTION. APPLICANTS MUST BE AT LEAST 16 YEARS OF AGE BY MAY 31ST, AND HAVE CPR FOR THE PROFESSIONAL RESCUER, FIRST AID, AND LIFEGUARD CERTIFICATION

Please provide copies of your certifications with your application.

County of Chemung