Application for Employment- Summer Intern

Return Application to:         Cass County Extension Office
C/O County Extension Director
200 Court Park, Room 302
Logansport, IN  46947
574-753-7750
amhillis@purdue.edu

Application Process:
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Personal Data
Please complete this application by either printing or typing.

Name _______________________________________ Date of Application __________________
Address _____________________________ City ____________________________ State ______
Zip Code ______________________ Phone Number___________________________
Email address________________________________ 

1.	Are you employed? ______ Yes  ______ No
2.	May we contact your present employer? ______ Yes  ______ No
3.	Can you travel if a job requires it? ______ Yes  ______ No
4.	If your application is considered favorably, on what date will you be available to work?
_________________________________________

Education

Do you have a high school diploma or GED?  □ Yes    □ No    
Name of School:  	

Are you currently attending or do you have a degree from a post-secondary institution? 
                    □ Attending    □ Graduated    

Name of Institution    	

Area of study   	

Please complete the table below for your last 3 places of employment.
Dates of Employment |
Employer's Name |
Employer's Address |
Employer's Phone |
Supervisor's Name |
Supervisor’s Email |
Position Held |
Salary |
Duties Performed |
Dates of Employment |
Employer's Name |
Employer's Address |
Employer's Phone |
Supervisor's Name |
Supervisor’s Email |
Position Held |
Salary |
Duties Performed |
Dates of Employment |
Employer's Name |
Employer's Address |
Employer's Phone |
Supervisor's Name |
Supervisor’s Email |
Position Held |
Salary |
Duties Performed |

Please describe your work experiences on the below. Please use an additional page if needed. 

1.	Describe your past 4-H experience ____________________________________________________
________________________________________________________________________________
2.	Describe why you would be interested in this position__________________________________
________________________________________________________________________________
3.	Describe your experience in working with volunteers ______________________________________
________________________________________________________________________________
4.	List the software that you are proficient in. (Include word processing, spreadsheets, databases, etc.) ________________________________________________________________________________
________________________________________________________________________________
_____________________________________________________________________

5.	Describe your experience in working/teaching youth ______________________________________
________________________________________________________________________________

6.	Share any prior experiences, coursework, or other skillsets that are applicable for this position__________________________________________________________________________
________________________________________________________________________________
 
References

Please list the name, address and phone numbers of three references who are not related to you and are not previous supervisors.
Name | Reason for Listing
Address |
Phone# |
Name | Reason for Listing
Address |
Phone# |
Name | Reason for Listing
Address |
Phone# |

PERSONAL INFORMATION

Do you have any commitments which might interfere with or adversely affect your employment with us, such as a second job or school? Yes 	No 	  If yes, please explain:

Have you ever been convicted of a felony that has not been expunged or sealed?
Yes	No 	If yes, please explain:

Do you have an arrest record that has not been expunged or sealed?  Yes	No  	
If yes, please explain:  	

Are you currently required to register as a sex offender in this or any other jurisdiction?
Yes	No	If yes, please explain (including jurisdiction of registry):   	

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Thank you for completing this application form and for your interest in employment with us. We would    like to assure you that your opportunity for employment with Cass County will be based on your merit and fitness and on no other consideration. Cass County does not discriminate on the basis of race, color, gender, national origin, age, religion, or disability, in employment or the provision of services.

Please Complete the Applicant Certification to Complete the Application.

******************************************************************************
APPLICANT CERTIFICATION
Read each of the following paragraphs carefully. Indicate your understanding of, and consent to, the contents and conditions of each paragraph by signing your initials at the end of each paragraph. If you have any questions regarding these paragraphs, contact the employer before initialing.

•	I understand and accept that, if I am hired, I may be hired conditional on passing any medical and/or psychological examinations that the employer deems necessary to determine my ability to perform the essential functions of the position. I understand and accept that this may include drug, alcohol or substance abuse testing.
  Initials:  	
•	I understand that it may be necessary for me to approve and sign any waivers necessary in order for the employer to obtain information from my current and former employers.

Initials:  	
•	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.
Initials:  	
•	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 my misrepresentations or falsification of the information provided may lead to withdrawal of an employment offer or termination following employment.

Initials:  	

By submitting this document, I hereby agree that I shall execute the employer's conditional and post- employment medical examination and drug testing consent requirements. I recognize that my future employment with the employer will be jeopardized if I engage in substance abuse, illegal drug use, or alcohol abuse.
									   Initials: ___________

Applicant signature	Date

Return Application to:	^Cass ^County ^Extension ^Office
^C/O ^County ^Extension ^Director
200 Court Park, Room 302
Logansport, IN 46947	
574-753-7750
amhillis@purdue.edu