EMPLOYMENT APPLICATION - Iowa State University



EMPLOYMENT APPLICATION

JACKSON CO. EXTENSION SUMMER YOUTH PROGRAM STAFF

RETURN TO: amber@iastate.edu or DUE: February 12, 2021

Jackson County Extension

201 West Platt Street

Maquoketa, IA 52060

Name: __________________________________________Phone _________________________________

Address________________________________________________________________________________

Email__________________________________________________________________________________

Are you legally authorized to work in the United States _____ Yes _____ No

Access to transportation? _____ Yes _____ No Email________________________________________

EDUCATION: Year

Name of Institution Location Graduated

High School: __________________________________________________________ _______

Post High School __________________________________________________________ _______

Major ______________________________________________

List courses taken or experience which are related to: Youth Development

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EMPLOYMENT:

Previous Experience Record: List chronologically work for which you have received regular payment. Include part-time work done while attending high school & college, entering most recent first:

Employer Job Title Date Started Date Left

__________________________ _____________________ ___/____/___ ____/___/___

Address Supervisor’s Name Starting Rate Final Rate

__________________________ ________________________ $_________ $ _________

Duties______________________________________________________________________________________________________________________________________________________________________________

Reason for Leaving: _________________________________________________________________________

Employer Job Title Date Started Date Left

__________________________ _____________________ ___/____/___ ____/___/___

Address Supervisor’s Name Starting Rate Final Rate

__________________________ ________________________ $_________ $ _________

Duties______________________________________________________________________________________________________________________________________________________________________________

Reason for Leaving: _________________________________________________________________________

Employer Job Title Date Started Date Left

__________________________ _____________________ ___/____/___ ____/___/___

Address Supervisor’s Name Starting Rate Final Rate

__________________________ ________________________ $_________ $ _________

Duties______________________________________________________________________________________________________________________________________________________________________________

Reason for Leaving: _________________________________________________________________________

EXPERIENCE:

Describe your experience with youth programs:

Boy Scouts ____ Girl Scouts ____ 4-H ____ FFA ____ Others (Please Specify):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe any other volunteer or leadership experience you have had:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

State briefly why you desire this position:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REFERENCES:

Name: ____________________________________Email__________________________________________

Mailing Address ___________________________________________________ Telephone # ____________

How long have you know him/her: _____________________________________

In what capacity do you know him/her:__________________________________________________________ _________________________________________________________________________________________

Name: ____________________________________Email__________________________________________

Mailing Address ____________________________________________________ Telephone # ____________

How long have you know him/her: ______________________________________

In what capacity do you know him/her: __________________________________________________________

__________________________________________________________________________________________

Name: ____________________________________Email__________________________________________

Mailing Address ____________________________________________________ Telephone # ____________

How long have you know him/her: ______________________________________

In what capacity do you know him/her: __________________________________________________________

__________________________________________________________________________________________

By signing this form, I attest that the above is an accurate and complete response to the above questions. I understand that any willful omission or misrepresentation may be grounds for dismissal from my position.

Date: ___________________ Signature: _________________________________________________

A RESUME MAY ALSO BE INLUDED.

RETURN BY FEBRUARY 12, 2021

Affirmative Action/Equal Employment Opportunity Employer

In accordance with ISU Extension’s Child Protection and Safety Policy, a Criminal Record Check will be completed by the Department of Public Safety on the applicant selected for this position.

Iowa State University and U.S. Department of Agriculture cooperating

Extension programs are available to all without regard to race, color, national origin, religion, sex, age or disability.

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