Canadian County Children’s Justice Center
EMPLOYMENT APPLICATION (rev. 01-11)
Canadian County is an equal opportunity employer and will consider all applicants for all positions equally without regard to their race, sex, age, color, religion, political affiliation, national origin, veteran status or disability as provided in federal and state regulations. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all information has been completed.
PERSONAL:
Date:
Home Phone:
Cell Phone:
Email Address:
Address
Social Security No.
Are you at least 18 years of age?
Are you a citizen of the U.S. or do you have the legal right to be employed in the United States?
Have you ever been convicted of any crime (excluding minor traffic violations) including driving while under the influence of
alcohol or other drugs?
If yes, state the offense, location, date and disposition (NOTE: A conviction will not necessarily disqualify you from employment)
Do you have the ability, with or without reasonable accommodation, to work overtime or to travel if required by the job for
which you are applying?
If no, please explain
Driver’s License:
State:
Number
Type
Currently Valid?
Do you authorize CCCJC to obtain a copy of your driving record?
Are you willing to submit to a drug test in accordance with facility policy?
Do you authorize CCCJC to obtain a criminal background check?
Have you or any of your immediate family received any type of services from Canadian County Children’s Justice
Center?
If yes, when were services completed or terminated?
List relatives employed by CCCJC and their relationship to you
EMPLOYMENT DESIRED:
temporary or summer employment
(check all that apply)
Position for which you are applying
Salary Desired
Date available to start
Have you ever applied for employment with this county before?
Have you ever worked for this county before?
If your answer to either of the above questions is yes, list when and where you applied and/or worked.
How did you learn of this position?
Are you now, or do you expect to be, working in any other business or job?
If yes, please explain
EDUCATION:
Name, Address and Location
High School:
Graduate?
Course of Study
Diploma:
Name, Address and Location
College:
Graduate?
Course of Study
Diploma:
Name, Address and Location
Trade School:
Graduate?
Course of Study
Diploma:
If you did not graduate, why did you leave high school or college?
Are you planning to pursue further studies?
If so, when, where and what courses?
List any scholastic honors, offices held and activities during high school and college
List and describe any other education or specialized training
MILITARY
Have you ever served in the military?
Service Branch
Date Entered
Date Separated
Final Rank
CAPABILITY I RELIABILITY:
Are you willing and able to perform all of the tasks required by the job you for which you are applying with or without
reasonable accommodation?
If no, explain which tasks you are unable or unwilling to perform
CAPABILITY I RELIABILITY (Cont’d):
If you are currently employed, may we contact your company?
Have you ever been fired or asked to resign from a job?
If yes, please explain
Will you abide by the safety rules of this agency?
Have you ever been disciplined for violating an employer’s safety rules or regulations?
If yes, please explain
How many days of work or school have you missed in the last two years?
How many times have you been late for work or school in the last two years?
Have you ever been disciplined or received verbal or written warnings for absenteeism or tardiness?
If yes, please explain
Are you willing and able to report to work on time every day on a regular and consistent basis?
If no, please explain
Please use the space below to describe why you are interested in working for our agency and list the skills and abilities that you feel particularly qualify you for a position with us. If you need more space, please continue on a separate sheet.
This section is to be completed by persons applying for positions in the detention center,
juvenile bureau or group home. All other applicants please skip to the work history section on
the next page.
Are you at least 21 years of age or older?
Are you willing and able to perform all of the tasks required by the job for which you are applying (including
physically restraining juveniles if it is part of your job description)?
Are there any days or hours you are unable or unwilling to work?
If yes, please specify
the days and/or the hours you are unable or unwilling to work
WORK HISTORY
List names of employers in consecutive order with CURRENT OR MOST RECENT EMPLOYER LISTED FIRST. Account
for all periods of time including military service and any periods of unemployment. If self-employed, give firm
name and supply business references. If you have had more than three employers, please attach an additional
page. DO NOT REFERENCE YOUR RESUME.
Name of
Employer
Address
Telephone
Nature of Business
Name & Title
of Last Supervisor
DATES
EMPLOYED
From
To
PAY
RATE
Starting
$
Ending $
Position Title
Reason For Leaving
Duties
Name of
Employer
Address
Telephone
Nature of Business
Name & Title
of Last Supervisor
DATES
EMPLOYED
From
To
PAY RATE
Starting $
Ending $
Position Title
Reason For Leaving
Duties
Name of Employer
Address
Telephone
Nature of Business
Name & Title of Last Supervisor
DATES EMPLOYED
From
To
PAY RATE
Starting $
Ending $
Position Title
Reason For Leaving
Duties
ADDITIONAL SKILLS
Have you had any computer or word processing experience or training?
If yes, please describe
What languages do you speak fluently?
REFERENCES
List three references, not relatives or former employers, who have known you for at least two years.
AFFIDAVIT
I certify that my answers on this application are true and correct. I understand that if I am employed, any false, misleading
or otherwise incorrect statements made on this application form or during any interviews may be grounds for my
immediate discharge. I hereby authorize Canadian County to contact any company or individual it deems appropriate to
investigate my employment and criminal history, character and qualifications. I give my full and complete consent to any
person or agency contacted by CCCJC to reveal any and all information they wish as a result of this investigation. In
addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion of privacy
or any other reason because of their statements. I hereby agree to allow CCCJC to perform a drug test and consent to
participate in said test as part of the application process. I agree that, if I am employed, I will abide by all the rules and
regulations of the agency. I understand that the taking of drug and alcohol tests, when given pursuant to county policy, are
a condition of continued employment and refusal to take such tests when asked will be grounds for my immediate
termination. I further understand that nobody in the agency is authorized to enter to any written or verbal employment
contracts with me for any definite period of time without the express written consent of the director of the agency. I also
understand that my employment is at-will and may be terminated by me or by the county any time for any reason or no
reason at all, with or without prior notice.
Signature
Date
Applicant Data Record
We are an Equal Opportunity Employer and do not discriminate on the basis of religion, sex, age, national origin, political affiliation,
mental or physical disability, race, color, or status as a disabled veteran and promote full realization of equal employment opportunity.
Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data
Record. We appreciate your cooperation. Completion of this survey is strictly voluntary and will not subject you to adverse treatment.
This data is for periodic government reporting and will be kept in a confidential file separate from the Application for Employment.
(PLEASE PRINT)
Date:
Position applied for:
Referral source:
The following data is for analysis and affirmative action only. Submission of information about a disability is voluntary.
Gender:
Race/Ethnic Group - Check one:
Veteran Status - Check one:
AUTHORIZATION FOR RELEASE OF INFORMATION
Applicant
Address
Birth date
Sex
Social Security
Have you lived in any other state(s) besides Oklahoma in the past three (3) years?
If yes, please list
This authorization is in compliance with the Privacy Act of 1974 (Public Law 93-579). The information you authorize
released will be used to verify data provided on your employment application or upon hiring and is necessary for
employment in a specific position. If any information you have provided is determined to be false after the hiring process is
complete, you will be terminated immediately. Information determined to be false prior to hiring will result in your not being
hired.
The information obtained as a result of your signature on this authorization will be furnished to designated officers and
employees of Canadian County to verify information necessary to process your employment/volunteer work with the
Canadian County Children’s Justice Center.
This authorization for release of information constitutes your consent for CCCJC to examine and/or obtain copies and
abstracts of records and to receive statements and information regarding your background. By signing this form you
authorize the release of data, records and information to Canadian County as designated below. Education, criminal and
employment verification will be obtained on every person hired. Other information will be verified as legally required for a
specific position.
Signature of Applicant
Date
