SCDOC Medical Application Form

Strafford County Department of Corrections
266 County Farm Road
Dover, NH 03820-6003
(603) 742-3310
Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Base Data

Your application

Please enter your application data here!

Select a job*

Employment date

How Did You Learn About Us?

Advertisement Friend Walk-In Employment Agency Relative Other

Personal Information

Please fill in your personal data here!

Last Name*

First name*

Middle Name

Any Prior Name(s) Used (such as maiden name, prior married name, or name change)

Address*

Number*

Zip*

City*

State*

Telephone Numbers

Availability

Best time to contact you at home is:

If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No

Have you ever filed an application with us before? Yes No

If Yes, give date

Have you ever been employed with us before? Yes No

If Yes, give date

Are you currently employed? Yes No

May we contact your present employer? Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No

On what date would you be available for work?

What is your desired salary range ?

Are you available to work full time ? Yes
No

Are you currently on “lay-off” status and subject to recall? Yes No

Can you travel if a job requires it? Yes No

Education

Elementary School

Name Address of School

Years Completed

Course of Study

Diploma Degree

High School

Name Address of School

Years Completed

Course of Study

Diploma Degree

Undergraduate School

Name Address of School

Years Completed

Course of Study

Diploma Degree

Graduate Professional

Name Address of School

Years Completed

Course of Study

Diploma Degree

Other (Specify)

Name Address of School

Years Completed

Course of Study

Diploma Degree

Work Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

(Present/Last Job)

Employer (Present/Last Job)

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Hourly Rate/Salary

Starting

Final

Dates Employed

From

Work Performed

Employer (First Most Recent)

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Dates Employed

From

Hourly Rate/Salary

Starting

Final

Work Performed

Employer (Second Most Recent)

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Dates Employed

From

Hourly Rate/Salary

Starting

Final

Work Performed

Employer (Third Most Recent)

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Dates Employed

From

Hourly Rate/Salary

Starting

Final

Work Performed

Include explanation of any gaps in employment

Explain any gaps in employment

Specialized training or skills

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the united states military

Job-related training received in the United States military

Specialized Skills - Check Skills/Equipment Operated

PC Calculator Typewriter Fax Spreadsheet Programs Excel Point Click Care Word Processing Programs Word MDS’s Other

Additional Information

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment, education, or other experience.

Other Skills or Information

State any additional information you feel may be helpful to us in considering
your application.

Notice to applicants

DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS
OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accomodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given. Yes No

Languages

Indicate any foreign languages you can speak, read and/or write.

Speak

Fluent Good Fair

Read

Fluent Good Fair

Write

Fluent Good Fair

References (Persons not related to applicant)

Name

Telephone #

Complete Mailing Address

Name

Telephone #

Complete Mailing Address

Name

Telephone #

Complete Mailing Address

Applicant’s Statement

I certify that answers given herein are true and complete.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. l hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an ''at will" nature. which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically. acknowledged in. writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I
understand, also, that I am required to abide by all rules and regulations of the employers.

Signature

Date

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

County Seal 1

STRAFFORD COUNTY DEPARTMENT
OF CORRECTIONS
266 County Farm Road
Dover, New Hampshire 03820
Telephone: (603) 742-3310
Fax: (603) 742-2192

I, do hereby authorize the Strafford County Department of Corrections to conduct a pre-employment personal history investigation. I further authorize the release of information contained in records,
reports and statements. In addition, I authorize the Strafford County Department of Corrections to conduct such character
reference interviews as may be deemed necessary by the department for the position for which I have applied.
Authorization is specifically granted to investigate and obtain records and information concerning the following:
1. Previous employment history.
2. Records of any criminal convictions that have not been annulled.
3. Motor vehicle driver history in this or any other state.
4. Record of any issued protective orders relative to domestic violence.
5. Any other data or information which has a direct bearing on the suitability for employment.
I hereby release said person( s), agencies or businesses that furnished or obtained such personal history information from
any and all liability which may have been incurred as the result of this personal history investigation. A photocopy of this
information release authorization will constitute as a valid document.

Have you ever been convicted of a crime that has not been annulled by a court and/or do you have any criminal charges pending against you? Yes No

If Yes, please explain

I understand that as part of my pre-employment or at the discretion of the Strafford County DOC Superintendent, I may be required to submit to drug testing and fingerprinting. If I refuse such testing, I may no longer be considered for employment and/ or my employment may be terminated. I understand that as part of my pre-employment, at the discretion of the Strafford County DOC Superintendent, I may be required to submit to a Polygraph Examination. Strafford County Department of Corrections is an Equal Opportunity Employer. Yes No

Name

Signature

Date

Date of Birth

Gender

Address

Telephone Number

Contact Data

Phone*

Email*

Security

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