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2. BUFFALO COUNTY EMPLOYMENT APPLICATION
   An Affirmative Action/Equal Opportunity Employer
   Administration Office
   407 S. 2nd St.
   Alma, WI 54610
   Phone: 608-685-6234 FAX: 608-685-6300

   Important: Read Carefully before filling out your application.

   Please type or print plainly in ink. This application must be complete to be considered for employment. You may attach a resume, but the resume may not be substituted for this official application in whole or in part. We will not refer to the resume for incomplete application answers. Study the essential qualifications listed in the position announcement. If you believe that you meet these qualifications, complete this application. Answer all questions applicable for the position for which you are applying. Be thorough. Your answers determine whether you will be considered for the position. Your completed application, together with any additional information specified in the position announcement, must be received not later than the closing date specified in the announcement. Incomplete or unsigned applications will not be processed.
4. Date Completed:*
5. Position Applying For:*
7. How did you hear about this position?*

   1. Newspaper/Bulletin/Magazine
   2. County Website
   3. Job Service
   4. Other
   5. Other Websites
9. PERSONAL
11. Name (Last, First, Middle Initial):*
13. Address:*
15. City *
16. State*
17. Zip*
19. E-mail Address:
21. Phone Number:*
23. 18 Years or Older?*

    1. Yes
    2. No
25. Are you legally eligible for employment in the US?*

    1. Yes
    2. No
27. Have you ever been convicted of offenses that would be directly related to the particular job for which you are applying?*

    1. Yes
    2. No
29. If yes, please give conviction dates and location:
31. Upload Your Resume
35. EXPERIENCE
37. Are you presently employed?*

    1. Yes
    2. No
39. May we contact your current employer?*

    1. Yes
    2. No
41. EXPERIENCE: Account for ALL TIME for at least the past 10 years, including relevant volunteer experience. If you were employed under another name, include the name by which you were known to your employer. In addition, you may list an earlier experience relevant to this position. Part-time work will be pro-rated in determining experience qualifications. Only those jobs listed will be considered in evaluating your qualifications. THIS SECTION MUST BE FULLY COMPLETED EVEN IF YOU SUBMIT A RESUME. Please explain gaps in employment.
43. NAME OF EMPLOYER
44. Job Title
45. Hours Worked Per Week
47. Address, City, State, Zip
49. Phone
51. Dates of Employment: From:
52. To:
54. Supervisor:
55. Starting Salary:
56. Ending Salary:
58. Description of Duties:
60. Reason for Leaving:
62. Number of People you supervised: Professional:
63. Non-Professional:
65. NAME OF EMPLOYER
66. Job Title
67. Hours Worked Per Week
69. Address, City, State, Zip
71. Phone
73. Dates of Employment: From:
74. To:
76. Supervisor:
77. Starting Salary:
78. Ending Salary:
80. Description of Duties:
82. Reason for Leaving:
84. Number of People you supervised: Professional:
85. Non-Professional:
87. NAME OF EMPLOYER
88. Job Title
89. Hours Worked Per Week
91. Address, City, State, Zip
93. Phone
95. Dates of Employment: From:
96. To:
98. Supervisor:
99. Starting Salary:
100. Ending Salary:
102. Description of Duties:
104. Reason for Leaving:
106. Number of People you supervised: Professional:
107. Non-Professional:
111. EDUCATION
113. Highest Level of Education
115. Name of School and Location
117. Did you graduate?

     1. Yes
     2. No
119. Course of Study:
120. Credits Earned:
122. Date:
124. List type of degree, diploma, or certificate:
126. List below any Continuing Education or Inservice Training you have completed relevant to the job for which you are applying not covered above.
128. Describe your Training and Experience that gives you the knowledge, skills, abilities and interest to perform the type of work for which you are applying.
132. REFERENCES
134. List three persons we may contact at this time who are NOT related to you and have definite knowledge of your qualifications for the position for which you are applying. Do not give names of supervisors listed under EXPERIENCE.
136. Name, Title, Business or Occupation:
138. Address:
140. Phone:
141. E-mail:
143. Name, Title, Business or Occupation:
145. Address:
147. Phone:
148. E-mail:
150. Name, Title, Business or Occupation:
152. Address:
154. Phone:
155. E-mail:
159. COMPLETE THE SECTIONS APPLICABLE TO THE POSITION YOU ARE APPLYING FOR
161. Are you currently certified, registered, or licensed for this position?

     1. Yes
     2. No
163. If yes, list name, number, date issued and expiration date.
165. Do you have a valid Driver's License?

     1. Yes
     2. No
167. Do you have a Commercial Driver's License?

     1. Yes
     2. No
169. Please list which classifications/endorsements you hold:
171. Typing (Words Per Minute):
172. Data Entry:

     1. 10-Key
     2. Alpha-Numeric
174. List office equipment you can operate:
176. List computer software programs you can operate:
178. Describe other skills you possess related to this position:
182. DISCLAIMER AND SIGNATURE
184. I certify that my answers are true and complete to the best of my knowledge and that intentional misrepresentations or omissions may be cause for the rejection of my application and that if hired I may be released from employment.

     I understand that the County may require me to successfully complete a pre-employment drug and alcohol test as a condition of employment and that continued employment may be based on the successful completion of similar tests.

     I understand that the County may as part of the hiring process request an investigative consumer report from a third party entity or agency including information concerning my character, general reputation, personal characteristic, credit records, and mode of living. I may make a written request to the County to provide me with additional information regarding the nature and scope of any such report.

     I understand that employment with your County is "at will" and nothing in the interview or hiring process, this application, or your County policies are intended to create an employment contract between myself and the County. Employment may be terminated by either part at any time for any reason with or without notice.
186. Signature*
187. Date*
191. TO: All Buffalo County Employment Applicants.

     RE: Open Records Law

     From: Buffalo County Administration

     According to the 1991-1992 Biennial Sessions Senate Bill Act 317, Wisconsin Statutes 19.36 (7)(a), applicatns for public employment can choose to have their application withheld from open records and possible publication by area news services.

     Also, due to Act 317, if an applicant is selected as a finalist for the public position and the applicant is interviewed with other finalists, the name and other pertinent information will become public record and may be used by the news media.

     Please indicate below with an "X" if you wish to have your name remain confidential initially.

     Please sign your name on the line below and return with your application. Than you for your cooperation.
193. My name is to remain confidential if requested by the public or new media. I understand that if I am considered one of the final candidates my name will then be released under the open records law.
195. Signature*
196. Date:*
200. BUFFALO COUNTY INSERT TO APPLICATION
202. Buffalo County is an equal employment opportunity employer and is committed to a policy of nondiscrimination and compliance with employment laws. In an attempt to judge the effectiveness of our recruitment efforts for affirmative action, we request you provide us with the following information.

     This information will be removed from your application. The Information is used for statistical purposes only and will not be used in the decision to hire or promote. Failure to disclose the data will have no effect on hiring decisions.
204. Applicant Name:
206. Position you are applying for:
208. Gender

     1. Male
     2. Female
210. Ethnic Group

     1. American Indian or Alaska Native
     2. Asian
     3. Black or African American
     4. Hispanic or Latino
     5. Native Hawaiian or other Pacific Islander
     6. White (not of hispanic origin)
     7. Two or more races
     8. I do not wish to answer.
211. Veteran Status:

     1. Non Veteran
     2. Disabled Veteran
     3. Recently Separated Veteran
     4. Active Duty Wartime or Campaign Badge Veteran
     5. Armed Forces Service Medal Veteran
     6. I do not wish to answer.
Leave This Blank:


213. 1. Receive an email copy of this form.
214. Email address

     This field is not part of the form submission.

215. Submit Submit and Print

* indicates a required field