Fill and Sign the Manheim Invoice Form

COUNTY OF MERCER OFFICE OF PERSONNEL 640 South Broad Street, P.O Box 8068, Trenton, NJ 08650 APPLICATION FOR EMPLOYMENT “An Equal Opportunity and ADA Employer” Brian M. Hughes County Executive Raissa L. Walker Personnel Director Mercer County residency required. PLEASE TYPE OR PRINT NAME (LAST) (FIRST) (MIDDLE) PRESENT ADDRESS (NUMBER & STREET) ARE YOU A RESIDENT OF MERCER COUNTY? YES NO SOCIAL SECURITY NO. (CITY) AREA CODE & PHONE # (STATE) (ZIP CODE) POSITION APPLYING FOR: LIST ALL HIGH SCHOOL, VOCATIONAL TRAINING SCHOOLS, COLLEGES, UNIVERSITIES OR GRADUATE SCHOOLS WHICH YOU ATTENDED NAME DATES ATTENDED GRADUATE FROM YES TO NO FROM YES TO NO FROM YES TO NO MAJOR AREA OF STUDY HAVE YOU EVER BEEN CONVICTED OF A CRIME, WHICH HAS NOT BEEN EXPUNGED BY THE COURT? YES DEGREE OR LICENCE NO IF YES, GIVE DETAILS AND DATES OF EACH DISPOSITION IN REMARKS SECTION. (A CONVICTION WILL NOT NECESSARILY PRECLUDE YOU FROM OBTAINING EMPLOYMENT UNLESS THE NATURE OF THE CONVICTION RELATES ADVERSELY TO THE POSITION SOUGHT.) MACHINES OPERATED AND/OR SPECIAL SKILLS: ALSO ANY OTHER LICENSES, Certifications OR INTERSHIPS RELATED TO YOUR SKILL PROFESSION OR TRADE: TYPING YES NO APPROX. SPEED ___________ SHORTHAND? YES NO APPROX. SPEED ____________ ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF A STATE OF NEW JERSEY PENSION OR RETIREMENT FUND IF YES, EXPLAIN IN REMARKS SECTION HAVE YOU EVER BEEN EMPLOYED BY THE COUNTY OF MERCER? YES NO IF YES, WHEN? FROM: ________________ TO: ________________ HAVE YOU PREVIOUSLY APPLIED FOR EMPLOYMENT WITH THE COUNTY OF MERCER? IF YES, WHEN? DATE REMARKS: YES NO YES NO EMPLOYMENT RECORD (BEGIN WITH PRESENT EMPLOYER) ATTACH ADDITIONAL SHEETS IF NECESSARY NAME & ADDRESS OF EMPLOYER BRIEF DESCRIPTION OF DUTIES TITLE: FINAL SALARY: DATES OF EMPLOYMENT: FROM: _________________ TO: _________________ FULL TIME PART TIME REASON FOR LEAVING: NUMBER OF HOURS PER WEEK: __________________ NAME & ADDRESS OF EMPLOYER BRIEF DESCRIPTION OF DUTIES TITLE: FINAL SALARY: DATES OF EMPLOYMENT: FROM: _________________ TO: _________________ FULL TIME PART TIME REASON FOR LEAVING: NUMBER OF HOURS PER WEEK: __________________ NAME & ADDRESS OF EMPLOYER BRIEF DESCRIPTION OF DUTIES TITLE: FINAL SALARY: DATES OF EMPLOYMENT: FROM: _________________ TO: _________________ FULL TIME PART TIME REASON FOR LEAVING: NUMBER OF HOURS PER WEEK: __________________ REFERENCES: (GIVE THREE NAMES OF UNRELATED PERSONS WHO YOU HAVE KNOWN FOR MORE THAN ONE YEAR) NAME ADDRESS TELEPHONE # POSITION FOR PERSONNEL USE ONLY I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. ANY FALSE OR MISLEADING STATEMENT WILL BE CAUSE FOR REJECTION OR REMOVAL. DATE OF APPLICATION: _____________ ___________ SIGNATURE: ________ __________________________________________