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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