Employment Application An Equal Opportunity Employer

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1 Employment Application An Equal Opportunity Employer PO Box East Market Street Xenia, Ohio The Greene County Public Library considers applications for all positions without regard to race, color, religion, creed, gender, national origin, age, genetic information, disability, maritial or veteran status, sexual orientation, or any other legally protected status. As you complete this application you may omit any information that would reveal your inclusion in any of the groups listed above. You may also attach a resume in addition to completing this application. (Please Print) APPLICANT INFORMATION Position(s) Applied For: Last Name First Name Middle Initial Street Address City State Zip Telephone Number (Home (Other Are you over the age of 18? (If under 18, hire must provide proof of eligibility to work) [ ] Yes [ ] No Have you ever filled out an application with us before? If yes, give date. [ ] Yes (Date: ) [ ] No Have you ever been employed with us before? If yes, give approximate dates, position and department. (Date: From: To: Position: Department: ) Does Greene County Public Library currently employ any of your relatives? If you are currently employed, may we contact your present employer?

2 Are you legally eligible to work in the United States? (Proof of citizenship or immigration status will be required upon employment). On what date would you be available for work? Do you prefer to work: [ ] full time [ ] part time [ ] substitute [ ] Library Aide At which Community Libraries are you willing to work? [ ] Beavercreek [ ] Cedarville [ ] Fairborn [ ] Jamestown [ ] Winters-Bellbrook [ ] Xenia [ ] Yellow Springs What days/hours are you available? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify an applicant from employment). If yes, explain: EDUCATIONAL BACKGROUND Type of School Name/ Location Number of Years Completed Graduate? Y of N Diploma/ Degree Earned Graduate School College Trade/Technical High School Other (Specify)

3 EMPLOYMENT EXPERIENCE List any work experience beginning with your present or most recent job. Supervisor: Dates Employed (month& year) From: To: Supervisor: Dates Employed (month& year) From: To: Supervisor: Dates Employed (month& year) From: To: Supervisor: Dates Employed (month& year) From: To:

4 ADDITIONAL INFORMATION OTHER QUALIFICATIONS: Summarize job-related skills and qualifications acquired from employment or other experience. REFERENCES Name Address Phone Professional or Personal APPLICANT'S STATEMENT I certify that the information provided by me on this application for employment is true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that if I am employed, any false or misleading information given in my application or interview(s) may result in discharge. Signature of Applicant: Date: Please submit application by mail or in person to: Human Resources Officer Greene County Public Library 76 East Market Street, PO Box 520 Xenia, Ohio 45385

5 If you are currently in high school, please complete: High School attending: Grade in School: Extracurricular Activities: Parent Guardian: Address: I f you are under that age of 18, what is your birthdate? :

6 Equal Employment Opportunity Information PO Box East Market Street Xenia, Ohio We are interested in finding out more about the types of people who apply for jobs with Greene County Public Library. The information you provide on this form is completely VOLUNTARY. Should you wish to complete the form, the information will be used solely for EEO purposes in compliance with the State and Federal laws and guidelines. The information will be held in a file separate from your application and will not be used for any employment decisions. Position(s) applied for: Date: Male Female Please check appropriate statement(s). Two or more races White (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Hispanic or Latino Asian ( Not Hispanic or Latino) Native Hawaiian or Pacific Islander (Not Hispanic or Latino) American Indian or Alaskan Native (Not Hispanic or Latino) All persons who identify with more than one races listed below. All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. All persons having origin in any of the Black racial groups of Africa. All persons of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture of origin regardless of race. All persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. All persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. All persons having origin in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Disabled Physical or mental disability which substantially limits one or more major life activities. You may submit this form along with your application, or to further ensure anonymity, mail form to: Payroll Clerk, Greene County Public Library, PO Box 520, 76 E. Market Street, Xenia, OH 45385

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