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Please type or print. An attached resume will not be considered as having provided the requested information.
Incomplete application(s) will not be considered. Applications will generally be accepted for advertised positions only.
Proof of citizenship or immigration status will be required upon employment.
__________________________
E-mail Address
(_____)________________
Telephone Number
Yes
Availability:
(_____)________________
Daytime Telephone Number
For checking prior records, provide other names under which you
are, or were known.
No
___________________________________________________
Full-time
Part-time
Regular Basis
Temporary Basis
Yes
Preferred work site(s):
No
Main (Lorain)
Yes
No
South (Lorain)
When? __________
Avon
North Ridgeville
Yes
No
A-6-00 rev.
When? __________
EDUCATION
Name and Location
Major Course
of Study
Total Years
Diploma/Degree
High School:
College:
Graduate School:
Other:
List other special training related to the position you are seeking, including special courses and/or certificates:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Specify foreign language(s) you know and rate knowledge: Poor, Fair, Good, Fluently
Language
Speak
Read
Write
EMPLOYMENT HISTORY Beginning with your most recent employer, please list your last three (3) employers.
______________________________________________ ________________________________
Name of Employer
Type of Business
______________________________________________ ________________________________
Address
Telephone
_______________________ _______________________________________________________
Name of Supervisor
Reason for Leaving
Dates Employed:
From __________ To __________
Yes
No
Yes
No
Yes
No
Have you been convicted of a crime(s) within the last seven (7) years?
Yes
No
________________________________________________________________
Nature of the conviction
A conviction will not automatically disqualify an applicant for consideration. The Lorain Public Library System will consider the type and seriousness of the crime, the frequency of violations, and the applicant's entire work record.
REFERENCES
Name
Give the name and address of three (3) references, including teachers and guidance
counselors who know your experience, scholarship or ability. (No friends or relatives,
please.) Under "relationship", specify in what capacity this person knows you.
Address
Phone
Occupation
Relationship To You
APPLICANT'S STATEMENT:
I certify that the answers given herein are true and complete to the best of my knowledge, and understand and
agree that any misrepresentation or omission on my application or related papers, or made during any oral interviews,
may result in refusal of employment or shall be considered grounds for dismissal.
I understand that consideration for employment in the position for which I am applying is contingent upon the
results of a reference and background check. I therefore authorize the Lorain Public Library System to investigate all
statements made on my application for employment, and to discuss the results of its investigations with those responsible for hiring. I further authorize the Lorain Public Library System to contact my former employer(s) and any listed references or other persons who can verify information, and I give my consent for former employer(s) and other contacted
persons to respond to questions pertaining to information on this application. Further, I release from liability such former
employer(s) or other persons contacted by and providing information to the Lorain Public Library System.
If separated from employment from the Lorain Public Library System for any reason, I authorize it to furnish any
information to persons seeking my employment references and release from liability it and/or any person giving or
receiving any such information.
I understand that this application is not, and is not intended to be, a contract of employment. I understand, also
that I am required to abide by all rules and regulations of the Lorain Public Library System. I have read, understand and
agree to the above.
_____________________________________________________
APPLICANT'S SIGNATURE
_________________________
DATE SIGNED
______________________
______________________
Employment Log:
Date employed: _______________ Position: __________________________ Grade/Step: __________________
Advertisement
Community Program
Employment Agency
School
Friend
Professional Publication
Other ____________________________________________
Black
Hispanic
Female
A-6a-00 rev.
30-40
40-50
50-60
60-70
Disabled
Over 70
DISCLOSURE STATEMENT
I hereby acknowledge that I have read the above disclosure statement and have understood it.
Signature: ___________________________________________________________________
Date: _______________________________________________________________________
An Equal Opportunity/Affirmative Action Employer
A-6b-00 rev.