Application For Employment Form - Library (Sample) Page 3
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4Employer Name: _________________________________________________________________________________
Address: _______________________________________________________________________________________
Telephone Number: ___________________________ Your Title: __________________________________________
Primary Duties: __________________________________________________________________________________
Supervisor: ______________________________________ Title: __________________________________________
Dates of employment (mm/yyyy): From ______________________________ To _____________________________
Salary: Starting ______________________________________ Ending _____________________________________
Reason for leaving: _______________________________________________________________________________
What other skills or abilities do you possess which make you feel suited for this position? _______________________
_______________________________________________________________________________________________
Please list computer hardware/software and office machines which you have experience working with: ____________
_______________________________________________________________________________________________
Do you have a valid driver’s license?
Yes
No If yes, State ____ Class ____ # _____________________
If applying for a driver’s position, list/describe any traffic violations or accidents in which you have been involved
during the last five years on a separate sheet of paper.
Have you ever been discharged or forced to resign from prior employment as part of a settlement agreement with an
employer other than one involving a human rights charge or claim in which you were the claimant/plaintiff?
Yes
No If yes, please identify the employer and describe the circumstances: _________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
How many days were you inexcusably absent from work during the preceding three (3) years other than absences due
to illness or injury to you or your immediate family? ____________
IV. Criminal Background Information
LARL may conduct a criminal background check on individuals upon making a contingent job offer. Please refer to
the job description for this position to determine if such a check will be conducted. If the job description states that a
criminal check will be conducted, no offer of employment shall become final until receipt of the results of the criminal
background check from the BCA, the content of which is acceptable to LARL, and formal approval by the appointing
authority.
V. Veteran Status
(complete only if you served in the U.S. armed forces)
Are you an honorably discharged veteran of the armed forces of the United States or are you otherwise eligible to
claim Veteran’s Preference Points?
Yes
No
Do you wish to claim Veteran’s Preference Points?
Yes
No
If you are a disable veteran and wish to claim additional point, please check here:
Proof of applicable military status/eligibility, such as a DD214 form, will be required in order to claim credits. Please
attach DD214 form or forward it within five (5) business days.
VI. Equal Employment Opportunity Statement
Lake Agassiz Regional Library is an equal opportunity employer and will not discriminate against any applicant or
employee on any grounds protected under federal, state, or local law, including race, color, creed, religion, age, sex,
national origin, ancestry, marital affectional preference, disability or status with regard to sources of income.
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12/2013
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