Platte County Seal
Employment
  Application
Platte County, Missouri, is an Equal Opportunity Employer
Position(s) Applied for:
First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Social Security:
If you are under 18 years of age, please indicate your date of birth 
Have you filed an application 
with Platte County previously? 
Have you been employed by  Platte County previously? 
If yes, when?
   If yes, when?
Are you currently employed? 
May we contact your present employer? 
If offered employment, are you able to provide proof of identity and authorization to work in the United States?
On what date would you be available for work?
Are you available to work:
Full Time
Part Time
Shift Work
Temporary
Are you currently on “lay-off” status and subject to recall?
Driver’s License number if driving is an essential job function:
Do you have a CDL? If yes, which class?
Have you been convicted of a felony?

If yes, please explain below

Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities.
You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.
Employer:
Address:
Telephone Number:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed From: To:
Starting Salary/Hourly Rate:
Ending Salary/Hourly Rate:
Employer:
Address:
Telephone Number:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed From: To:
Starting Salary/Hourly Rate:
Ending Salary/Hourly Rate:
Employer:
Address:
Telephone Number:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed From: To:
Starting Salary/Hourly Rate:
Ending Salary/Hourly Rate:
Employer:
Address:
Telephone Number:
Job Title:
Supervisor:
Reason for Leaving:
Dates Employed From: To:
Starting Salary/Hourly Rate:
Ending Salary/Hourly Rate:
Education
Do you have a high school diploma or equivalent?
If not, what is the highest grade you completed?:
Please list all education below, beginning with high school.
High School
Technical/Vocational
College
Course of study
Hours
Degree
Course of study
Hours
Degree
Course of study
Hours
Degree
 

Skills and Certifications
List all valid professional licenses and registrations you hold. Include the certification/registration number and the date of expiration.

Indicate other employment skills, special training or additional information to consider regarding your application.
(You may exclude all information indicative of age, sex, race, religion, color, national origin or disability.)


References
Please list three people who we may contact to verify information contained within this employment application

1            Name:
   Phone:
Address
City:
State:
Zip:
2            Name:
   Phone:
Address
City:
State:
Zip:
3            Name:
   Phone:
Address
City:
State:
Zip:


Applicant’s Statement

I certify that the above statements are correct, and if employed, understand that any false information in this
application, or its supporting documents, will be sufficient grounds for termination without notice. I further agree
that all rules, orders and regulations of Platte County affecting my employment shall constitue a part of my
appointment or employment.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship
with Platte County is of an “at will” nature, meaning that I can resign at any time and that I may be discharged at any
time, with or without cause. It is further understood that this “at will” employment relationship may not be changed
by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized
executive of Platte County.

My signature authorizes Platte County to review my previous employment, driving and criminal records, and other
background data as it relates to the position(s) for which I am applying.

Signature - Please Type Your Full Name
By checking this box, I confirm my signature - Required.
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