Employment Application An Equal Opportunity Employer

PO Box 520

•

76 East Market Street

• Xenia, Ohio 45385

• 937-352-4000

The Greene County Public Library considers applications for all positions without regard to race, color,

religion, creed, gender, national origin, age, genetic information, disability, maritial or veteran status,

sexual orientation, or any other legally protected status. As you complete this application you may omit

any information that would reveal your inclusion in any of the groups listed above. You may also attach

a resume in addition to completing this application.

(Please Print)

APPLICANT INFORMATION

Position(s) Applied For: 1. _____________________ 2. __________________ 3. _________________

Last Name ___________________________ First Name ___________________Middle Initial_______

Street Address ___________________________City ________________ State_______ Zip _________

Telephone Number (Home) _______________________ (Other) _______________________________

Are you over the age of 18? (If under 18, hire must provide proof of eligibility to work) [ ] Yes [ ] No

Have you ever filled out an application with us before? If yes, give date.

[ ] Yes (Date: _________) [ ] No

Have you ever been employed with us before? If yes, give approximate dates, position and department.

[ ] Yes [ ] No (Date: From: ____ To: ____ Position: __________________ Department: _________)

Does Greene County Public Library currently employ any of your relatives?

[ ] Yes [ ] No

If you are currently employed, may we contact your present employer?

[ ] Yes [ ] No

Employment

Application

Are you legally eligible to work in the United States? (Proof of citizenship or immigration status will be

required upon employment).

[ ] Yes [ ] No

On what date would you be available for work? _________________________

Do you prefer to work: [ ] full time [ ] part time

[ ] substitute [ ] Library Aide

At which Community Libraries are you willing to work?

[ ] Beavercreek [ ] Cedarville [ ] Fairborn [ ] Jamestown [ ] Winters-Bellbrook [ ] Xenia [ ] Yellow Springs

What days/hours are you available? Monday _________ Tuesday ________ Wednesday __________

Thursday __________

Friday ___________ Saturday ___________ Sunday _____________

Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify

an applicant from employment).

[ ] Yes [ ] No

If yes, explain: _______________________________________________________________________

EDUCATIONAL BACKGROUND

Type of

School

Name/ Location

Number of

EMPLOYMENT EXPERIENCE

List any work experience beginning with your present or most recent job.

Employer: ______________________________________________ Telephone: ( ) ____________________ Address: ___________________________________________________________________________________ Supervisor: _______________________________ Dates Employed (month& year) From: ________ To: _______ Job title & duties: ____________________________________________________________________________ Reason for leaving: ___________________________________________________________________________

Employer: ______________________________________________ Telephone: ( ) ____________________ Address: ___________________________________________________________________________________ Supervisor: _______________________________ Dates Employed (month& year) From: ________ To: _______ Job title & duties: ____________________________________________________________________________ Reason for leaving: ___________________________________________________________________________

Employer: ______________________________________________ Telephone: ( ) ____________________ Address: ___________________________________________________________________________________ Supervisor: _______________________________ Dates Employed (month& year) From: ________To: _______ Job title & duties: ____________________________________________________________________________ Reason for leaving: ___________________________________________________________________________

ADDITIONAL INFORMATION

OTHER QUALIFICATIONS:

Summarize job-related skills and qualifications acquired from

employment or other experience.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

REFERENCES

Name

Address

Phone Professional or Personal

1.__________________________________________________________________________________

2.__________________________________________________________________________________

3.__________________________________________________________________________________

4.__________________________________________________________________________________

APPLICANT'S STATEMENT

I certify that the information provided by me on this application for employment is true and complete to

the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be

necessary in arriving at an employment decision.

I understand that if I am employed, any false or misleading information given in my application or

interview(s) may result in discharge.

Signature of Applicant: ____________________________________

Date: ___________________

Please submit application by mail or in person to:

Human Resources Officer

Greene County Public Library

76 East Market Street, PO Box 520

PO Box 520

•

76 East Market Street

• Xenia, Ohio 45385

• 937-352-4000

  We are interested in finding out more about the types of people who apply for jobs with Greene County Public  Library.  The information you provide on this form is completely VOLUNTARY.  Should you wish to complete the  form, the information will be used solely for EEO purposes in compliance with the State and Federal laws and  guidelines.  The information will be held in a file separate from your application and will not be used for any  employment decisions.    Position(s) applied for:  ____________________________________________________    Date: ___________________________    □     Male    □   Female    Please check appropriate statement(s).      □ Two or more races        All persons who identify with more than one         races listed below.   

□  White (Not Hispanic or Latino)  All persons having origins in any of the original peoples of Europe,  North Africa or the Middle East.    □  Black or African­American  All persons having origin in any of the Black racial groups of Africa.  (Not Hispanic or Latino)  □ Hispanic or Latino  All persons of Cuban, Mexican, Puerto Rican, South or Central  American or other Spanish culture of origin regardless of race.