Employment Application General Employment Application Please use this online form when applying for available Cheshire County job openings. NOTE: If you are applying for a position within Sheriff's Office or Department of Corrections, please use the following online applications: Sheriff's Office Employment Application Department of Corrections Employment Application Thank you. Position applying for:*Select a position4-H Program ManagerCOURT SECURITY OFFICER - PER DIEMDeputy SheriffDIETARY AIDESFAST Forward Care CoordintorIT Operations Technician ILAUNDRY AIDE - Baylor PositionLNA - All ShiftsLPN / RN - MAPLEWOOD NURSING HOMELPN/RN - DEPARTMENT OF CORRECTIONSLPN/RN for DEPARTMENT OF CORRECTIONSNursing Supervisor 11pm - 7amNursing Supervisor 3pm - 11pmOccupational Therapist - Full TimePHYSICAL THERAPIST - FULL TIMEPOLICE COMMUNICATIONS SPECIALIST (DISPATCHER)Prep Cook - Department of CorrectionsTrECC CoordinatorWard AidesDate available: MM slash DD slash YYYY Salary range: Type of employment desired: Full-Time Part-Time Per Diem Internship Available to work: Day Evening Night Weekend Please read the following statements carefully before you sign and complete this application.Equal Opportunity Employer*Cheshire County, believes in the principles and practice of equal opportunity. Cheshire County is an Equal Opportunity Employer and considers all qualified applicants and employees for hire, promotion, training, and all other employee action without regard to race, color, religion, age, national origin, ancestry, sex or sexual orientation, marital status, disability, citizenship, veteran status, or any other protected category under applicable federal, state or local laws. I have read, understand and agree to this statementEmployment-at-will Agreement*I understand that the employment relationship for which I am applying is an employment-at-will relationship. This means the employment relationship is by mutual consent of Cheshire County and myself, is not for any definite period of time, and may be terminated by either Cheshire County or me at any time, without notice, and for any reason or no reason at all. I further understand that this application and the policies, procedures, and benefits contained in any employee handbook or in any other written material disseminated by or for Cheshire County do not constitute an employment contract between Cheshire County and myself or imply the existence of any contractual or other rights. Such policies, procedures, and benefits contained therein may be changed or terminated from time to time by Cheshire County at its sole discretion. These statements about the at-will nature of employment constitute the complete understanding between the company and its employees regarding this subject. I have read, understand and agree to this statementBackground Check Authorization*Cheshire County, in considering my application for employment, may verify the information set forth on this application and obtain additional information related to my background. I expressly authorize Cheshire County or its agents to check my employment references, personal references, schools, etc., to determine my suitability for employment. I authorize all persons, schools, companies, corporations, and law enforcement agencies to supply any information concerning my background, and I release them from all liability for any damage for providing this information. I have read, understand and agree to this statementAccuracy Certification*I certify that the information on this application is correct and true. I understand that any misrepresentations or omission of any information may result in my disqualification from consideration for employment or, if employed, my dismissal. I agree that Cheshire County shall not be liable in any respect if my application is disqualified or my employment terminated because of misrepresentations, omissions, or false statements or answers by me either verbally, in writing, or on this application. I have read, understand and agree to this statementConsent to drug test, background check, and physical*I understand that any offer of employment at Cheshire County is contingent upon passing a drug test, criminal background check and physical. I have read, understand and agree to this statementPersonal InformationName:* First Middle Last Home Phone:Work Phone:Cell Phone:Email Address:* Current Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you eligible for employment in the United States?* Yes No If you are under 18 years of age and it is required, can you furnish a work permit? Yes No Referral source: Walk-in Advertisement Radio Employee Relative Other If referral source above is "Other", please specify: Have you ever been employed here before?* Yes No If yes give dates from: MM slash DD slash YYYY If yes give dates to: MM slash DD slash YYYY Is driving a job function of the position for which you are applying?* Yes No Driver's License Number: Driver's License State: Driver's License Expiration Date: MM slash DD slash YYYY If yes to any questions below, you will be asked to identify the crime or activity for which you were convicted or sanctioned, the date of the conviction or sanction and the location of the court in which you were convicted, or the identity of the government agency that sanctioned you. Please provide any details you feel relevant. Conviction of a crime will not necessarily bar you from employment but will be considered as part of the overall evaluation of your qualifications.Have you been convicted of a crime other than a minor traffic violation in the past?* Yes No Provide details:Have you ever been found guilty of abusing, neglecting or mistreating any person, or misappropriating the property of any person by a court of law?* Yes No Provide details:Have you ever been found guilty of abusing, neglecting or mistreating any person, or misappropriating the property of any person by a State Survey and Certification agency?* Yes No Provide details:Have you ever had a finding of guilty entered into any State Nurse Aide Registry concerning the abuse, neglect or mistreatment of the property of any person?* Yes No Provide details:Have you ever been convicted of a crime or sanctioned for violation of law relating to a Federally or State funded health care program or plan, including but not limited to the filing of a false or fraudulent claim for payment, the making of a prohibited referral, or the prohibited solicitation or receipt of remuneration for the making of a referral?* Yes No Provide details:EducationHigh School Graduated? Yes No Have you attended any Colleges or Universities?* Yes No If you answered yes, press the Add Entry button that will appear below to begin entering your College/University history.College/University History Institution Name Address Units Completed Major/Minor Degree Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Professional license, designations, etc.: Professional organizations: Specialized training or skills: Employment HistoryCurrent Employment Company Name Date Employment Started Rate of Pay at Start of Employment Rate of Pay at Departure Job Description How to Contact Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Previous Employment Company Name Date Employment Started Date Left Reason for Leaving Rate of Pay at Start of Employment Rate of Pay at Departure Job Description How to Contact Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. May we contact your current and former employers?* Yes No If you were employed under a maiden name or nickname or other name, what was the name? ReferencesList three persons, NOT related to you…. two MUST be professional referencesReference #1 Name:* First Last Reference #1 Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Reference #1 Relationship:* Reference #1 Years Known:*Reference #2Reference #2 Name:* First Last Reference #2 Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Reference #2 Relationship:* Reference #2 Years Known:*Reference #3Reference #3 Name:* First Last Reference #3 Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Reference #3 Relationship:* Reference #3 Year Known:*