LINN COUNTY EXTENSION by HC121001024625

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									                                       BUCHANAN COUNTY EXTENSION
                                          2600 Swan Lake Blvd. Ste. A
                                           Independence, Iowa 50644
                                                  Phone (319) 334-7161

                                          EMPLOYMENT APPLICATION
Full Time
Buchanan County Program Coordinator


                                          Application Due: October 1, 2011
                                  An Equal Opportunity/Affirmative Action Employer

NOTE: Mail completed application along with cover letter and resume to: Amy Kelly, Outreach Coordinator,
2600 Swan Lake Blvd. Ste. A, Independence, Iowa 50644 or Email: amykelly@iastate.edu

Additional Employment History forms available upon request if needed OR attach a separate sheet in same format.
____________________________________________________________________________________________

1. Full Name _______________________________________________________________________________
                                Last                                 First                              Middle

2. Telephone Number(s) ____________________________                          __________________________________
                              Area Code/Primary/Home Number                    Area Code/Alternate number

3. Address: _________________________________________________________________________________
              Street/P.O. Box/Apt. #                          City                        State                  Zip

4. Are you 18 years or older? ______ (Yes/No)

5. Are you a U.S. Citizen? ______ (Yes/No)

6. Have you had prior employment with Buchanan County Extension? If yes

   ___________________________________________________                       ______________________________
                                                                                      Date(s)

7. Have you ever been convicted of a misdemeanor or felony? ______ (Yes/No)
      If yes,* for what, where and when: _________________________________________________________
      *A criminal conviction is not an absolute bar to employment but will only be considered in relationship
      to specific job requirements.
8. Are you related to any Buchanan County Extension employee who is in a supervisory position at Extension?
        ______ (Yes/No)

       If so, indicate employee’s name and department.


       ____________________________________________________                      ______________________________
              Name(s)                                                                 Department(s)
                                                                1
NAME ___________________________________________________


                                                           EDUCATIONAL DATA

                                 High School Graduate or Equivalent (GED)? ______ (Yes/No)
                                                  You may be required to provide a transcript

Name and location of college, university, vocational/technical
schools
         (Most recent first)                                         From            To                                      Credit   Degree
                                                                     Mo.       Yr.   Mo.     Yr.     Major or Course Title   SH/QH
a.

b.

c.

d.


  A. If you had more than one position with the same employer, list each separately
  B. If a job was part time, list the average number of hours worked per week.
  C. When describing a job, list 3 or 4 major tasks performed and the approximate percentage of time spent on each task


                                                      1.    EMPLOYMENT HISTORY (Current)

Employer __________________________________________                                        Duties: (Be Specific)
Employer’s Address & Phone # ________________________                                      (1.) ____% _______________________________
____________________________________________________                                       _________________________________________
Type of Business _____________________________________                                     _________________________________________
Supervisor’s Name ____________________________________                                     _________________________________________
Your Title ___________________________________________                                     _________________________________________
Employed from ________________ to ____________________                                     (2.) _____% ______________________________
                       month/year                       month/year                         _____________________________________________
Average hours per week employed ______________________                                     _________________________________________
Reason for leaving ____________________________________                                    _________________________________________
_____________________________________________________                                      _________________________________________
List all machines/equipment/software used on the job:                                      (3.) _____% ______________________________
_____________________________________________________                                      _________________________________________
_____________________________________________________                                      _________________________________________
_____________________________________________________                                      _________________________________________
_____________________________________________________                                      _________________________________________
_____________________________________________________                                      (4.) _____ % ______________________________
List number and titles(s) of employees supervised:                                         _________________________________________
_____________________________________________________                                      _________________________________________
_____________________________________________________                                      _________________________________________
_____________________________________________________                                       _________________________________________

                                                                           2
NAME ___________________________________________________


                                    2.   EMPLOYMENT HISTORY (Current)

Employer __________________________________________        Duties: (Be Specific)
Employer’s Address & Phone # ________________________      (1.) ____% _______________________________
____________________________________________________       _________________________________________
Type of Business _____________________________________     _________________________________________
Supervisor’s Name ____________________________________     _________________________________________
Your Title ___________________________________________     _________________________________________
Employed from ________________ to ____________________     (2.) _____% ______________________________
               month/year            month/year            _____________________________________________
Average hours per week employed ______________________     _________________________________________
Reason for leaving ____________________________________    _________________________________________
_____________________________________________________      _________________________________________
List all machines/equipment/software used on the job:      (3.) _____% ______________________________
_____________________________________________________      _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________      (4.) _____ % ______________________________
List number and titles(s) of employees supervised:         _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________       _________________________________________




                                    3.   EMPLOYMENT HISTORY (Current)

Employer __________________________________________        Duties: (Be Specific)
Employer’s Address & Phone # ________________________      (1.) ____% _______________________________
____________________________________________________       _________________________________________
Type of Business _____________________________________     _________________________________________
Supervisor’s Name ____________________________________     _________________________________________
Your Title ___________________________________________     _________________________________________
Employed from ________________ to ____________________     (2.) _____% ______________________________
               month/year            month/year            _____________________________________________
Average hours per week employed ______________________     _________________________________________
Reason for leaving ____________________________________    _________________________________________
_____________________________________________________      _________________________________________
List all machines/equipment/software used on the job:      (3.) _____% ______________________________
_____________________________________________________      _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________      (4.) _____ % ______________________________
List number and titles(s) of employees supervised:         _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________      _________________________________________
_____________________________________________________       _________________________________________

                                                   3
NAME ___________________________________________________


                                           4.   EMPLOYMENT HISTORY (Current)

Employer __________________________________________                    Duties: (Be Specific)
Employer’s Address & Phone # ________________________                  (1.) ____% _______________________________
____________________________________________________                   _________________________________________
Type of Business _____________________________________                 _________________________________________
Supervisor’s Name ____________________________________                 _________________________________________
Your Title ___________________________________________                 _________________________________________
Employed from ________________ to ____________________                 (2.) _____% ______________________________
                  month/year                month/year                 _____________________________________________
Average hours per week employed ______________________                 _________________________________________
Reason for leaving ____________________________________                _________________________________________
_____________________________________________________                  _________________________________________
List all machines/equipment/software used on the job:                  (3.) _____% ______________________________
_____________________________________________________                  _________________________________________
_____________________________________________________                  _________________________________________
_____________________________________________________                  _________________________________________
_____________________________________________________                  _________________________________________
_____________________________________________________                  (4.) _____ % ______________________________
List number and titles(s) of employees supervised:                     _________________________________________
_____________________________________________________                  _________________________________________
_____________________________________________________                  _________________________________________
_____________________________________________________                   _________________________________________


Tell us about your skills and experience relating to this position. (attach page if needed).
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Three references that could speak of your skills and experiences relating to this position:
Name: _____________________________ Cell # ____________ Work # ______________ Home: ______________

Name: _____________________________ Cell # ____________ Work # ______________ Home: ______________

Name: _____________________________ Cell # ____________ Work # ______________ Home: ______________
                                                           -4-
                                            Certification & Authorization

I certify that the information provided in my application for employment is true and complete to the best of my
knowledge. I understand that any misrepresentation or omission of information may constitute rejection of my
application for employment or may be cause for termination if employed.

I authorize representatives of Iowa State University Extension to contact any of my former employers, the educational
institutions that I have attended, or any other person organizations who have information relevant to my application
for employment and for those individuals or organizations to release information relevant to my application for
employment.




Signature: _____________________________________________________ Date: ______________________________




Mail this completed application form along with a cover letter and resume to: Amy Kelly, Outreach Coordinator,
2600 Swan Lake Blvd. Ste. A, Independence, Iowa 50644




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