WASHINGTON COUNTY

EMPLOYMENT APPLICATION
197 E. Tabernacle
St. George, UT 84770
(435) 652-5821

RETURN APPLICATION TO: Workforce Services 162 N. 400 E., Bldg B, St. George UT

I. APPLICANT INFORMATION

Title of position applied for:

Type of employment desired: Full Time Part Time Temporary

Date available for employment:

Name: Soc. Sec. #

Address:
Street City State Zip

Telephone:
Day Evening Work

Are you related to someone currently employed by Washington County? Yes No

*Name Relationship

If employed, are you willing to accept the approved salary for this position? Yes No

Have you ever been employed by Washington County? Yes No Year & Dept.

WASHINGTON COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER

It is the policy of Washington County Government to provide and promote equal opportunity employment,
compensation and other terms and conditions of employment without discrimination because of race, color, sex,
religion, national origin, age or disability. The County provides reasonable accommodations to the known
disabilities of applicants in compliance with the Americans with Disabilities Act.

II. TRAINING, EDUCATION AND EXPERIENCE: You must complete all applicable items in this section,
or your application may be rejected. The information you give regarding your training and experience will be used
to determine if you meet minimum qualifications.

TRAINING: When claiming college, business, armed forces or vocational school credit, you must submit transcripts or
other official documents (original or photocopy) with your application.
EDUCATION AND TRAINING

Have you graduated from high school or received If no, circle the highest grade completed:
a high school equivalency diploma? (GED)? Yes No 1 2 3 4 5 6 7 8 9 10 11 12
College, Business or Trade School CREDITS COMPLETED Degree Certificate
or Special Training SEMESTER QUARTER Major or Years Attended
HOURS HOURS

LANGUAGES: List languages you speak, read and write other than English

TYPE SPEED Net words per minute.

EXPERIENCE: Begin with your present or most recent job and describe, in the boxes below, all periods of
employment such as paid (full or part time), volunteer (full or part time), self employment, and/or military service.
Account for your time during any intervals of unemployment other than when attending school. Attach addendum if
necessary, using the same format.

Employer’s Name and Phone Number:

Complete Address:
Your Title: From To
Full Time - Part Time - Volunteer – Other Hours per week Last monthly pay $
Supervisors Name, Title, and Phone Number
Duties:

Reason for leaving or seeking other employment:

Employer’s Name and Phone Number:

Complete Address:
Your Title: From To
Full Time - Part Time - Volunteer – Other Hours per week Last monthly pay $
Supervisors Name, Title, and Phone Number
Duties:

Reason for leaving or seeking other employment:

 Employer’s Name and Phone Number:
Complete Address:
Your Title: From To
Full Time - Part Time - Volunteer – Other Hours per week Last monthly pay $
Supervisors Name, Title, and Phone Number
Duties:

Reason for leaving or seeking other employment:

Employer’s Name and Phone Number:

Complete Address:
Your Title: From To
Full Time - Part Time - Volunteer – Other Hours per week Last monthly pay $
Supervisors Name, Title, and Phone Number
Duties:

Reason for leaving or seeking other employment:

Additional Qualifications and Skills: Machines, Equipment, Tools Used, Related Activities, etc.

III. REFERENCES: List three persons who are not related to you and who have definite knowledge of your
qualification for the position for which you are applying.
Full Name Present Business or Home Address Business or Phone Number
(Street, City, State Zip) Occupation

Yes No 1. Have you, since the age of 18, been convicted of a crime, excluding minor traffic offenses? If
yes, give dates, details and penalties for each occurrence, including dates of any probationary
periods on a separate sheet. (Note: Each conviction will be judged in relation to time, seriousness,
circumstances, and relationship to the position sought, and will not necessarily bar you from
employment).

Yes No 2. Have you ever been discharged or forced to resign? If yes, please explain on a separate sheet.

Yes No 3. Would accommodation/assistance be helpful to you in taking the examination for this position?
If yes, describe on a separate sheet.

Yes No 4. If the position for which you are applying is hazardous in nature, including but not limited to working
with or around heavy equipment or hazardous material (see posted job announcement), are you 18
years of age or older?
Yes No 5. Are you a citizen by birth, or a naturalized citizen of the U.S.?

Yes No 6. If no, are you eligible to work in the U.S.?

Yes No 7. Are you willing to have your current employer contacted regarding your employment record?

IV. READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS STATEMENT

I hereby authorize any previous employer to give and release to Washington County any and all information of whatev-
er kind in either written or verbal form which relates to my ability to perform the duties of the position for which I am
applying. I release Washington County from any liability for the use of this information in considering and reviewing
my application for the available position.

I also agree to allow Washington County to determine my competence for certain positions in the sheriff and corrections
department or in departments where funds are involved, by obtaining credit, criminal and other job related information
about me.

I understand that this employment application and any other County documents are not contracts of employment and that
any oral or written statements to the contrary are hereby expressly disavowed.

I certify that all statements made in this application are true and complete, and understand that any misrepresentation of
material fact may subject me to disqualification or dismissal.

Signature: Date:

V. COMPLETE THIS SECTION ONLY FOR LAW ENFORCEMENT RELATED POSITIONS

Yes No Are you currently POST (Peace Officer Standards and Training) certified in this state or another state?

If yes, specify state Types of Certification:

(Please attach a copy of your certification)

Yes No Are you 21 years of age or older: (Law Enforcement/Corrections only)

READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS STATEMENT: Having made application for
employment with Washington County Government for the position of _________________, I hereby authorize
Washington County Government to conduct a detailed background investigation and understand that all information
pertaining to such application and investigation will be kept confidential and released to only authorized individuals.
I understand that should any investigation disclose any misrepresentation, falsification, omission or concealment of
material fact, my application may be rejected and my name removed from the eligibility list, and if already
appointed, I may be dismissed. I also understand that certain information or offenses may preclude me from
further consideration or result in termination. I hereby release your organization or any other agency involved in
releasing this information from any civil or criminal liability arising under the Federal Rights and Privacy Act or
other applicable State and County statutes.

Signature of Applicant (original, not photocopy) Date