Form Center

Step One

Instructions
Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Submit additional email if you do not have enough room. Be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.
Today’s Date
Today’s Date
Job Applied for*
Include the road district if applying for a Road and Bridge position
Department Applying To*
Please select the department you are applying to. This will ensure the correct department receives your application.
How Did Your Hear About the Position(s)?
What kind of Employment Are You Seeking?
Last Name*
First Name*
Middle Initial
Email Address*
Phone Number*
Present Street Address
Address2
City
State
Zip
Resume
Upload resume - MS Word or PDF format recommended
Cover letter
Upload cover letter- MS Word or PDF format recommended
Continue

Step Two

Additional Information

Acknowlegement
Please note that the hiring department may request additional information including, but not limited to, previous work history and education.
Applicant Initials
Please type your initials in the box to indicate that you have read and understand that the County may request additional information.
Continue |Go Back

References

Have you worked or attended school under any other names?
1. Yes
2. No
If yes, give names
Are you presently employed?
1. Yes
2. No
If yes, whom do you suggest we contact?
Have you ever been fired from a job or asked to resign?
1. Yes
2. No
If yes, please explain
Give 3 references. Only references from former employers will be accepted and considered.
Name*
Phone*
Address1
Address2
City
State
Zip
Name*
Phone*
Address1
Address2
City
State
Zip
Name*
Phone*
Address1
Address2
City
State
Zip
Continue |Go Back

Step Five

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING*
PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release and hold harmless such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination and background check. I consent to the release of any or all medical and criminal information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand and agree that if I am required to operate a motor vehicle as part of my job duties as a San Miguel County employee, as a condition of employment that San Miguel County is authorized to obtain and continue to monitor my driving records. The standards for operating a motor vehicle for San Miguel County are as follows: The applicant must posses a valid license to operate the type and class of vehicle they will be permitted or required to drive. The applicant must have no restrictions that would prevent them from legally or safely operating the assigned vehicle. Where applicable, the applicant must present a current DOT Physical Examination Card and a Certification of a Road Test. Applicant must have no convictions for misdemeanor traffic offenses within the previous 3-year period. Misdemeanor traffic offenses include but are not limited to DUI, DWI, vehicular homicide, reckless driving, hit and run, or other offenses that would indicate flagrant disregard for public safety. Applicant must have no more than two at-fault or chargeable accidents within the previous 3-year period. Applicant must have no more than three traffic infractions in the previous twelve month period. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE BOARD OF COUNTY COMMISSIONERS (“BOARD”) OR THE COUNTY ADMINISTRATOR HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY THE BOARD OR COUNTY ADMINISTRATOR AND THE EMPLOYEE. I have read, understand, and by my signature consent to these statements
1. I have read, understand, and by my electronic signature consent to these statements.
Continue |Go Back

Step Six

Consumer Report Disclosure & Authorization
As part of our hiring process, San Miguel County may request Consumer Reports and/or Investigative Consumer Reports on you from an Investigative Reporting Consumer Reporting Agency solely for your potential/current and or continued employment with this company. The nature and scope of this investigation may include but is not limited to your employment history, education, credit history, criminal history, character, general reputation, personal characteristics and mode of living and may involve a review of criminal records and records of the Department of Motor Vehicles. San Miguel County may obtain one or more consumer reports on you, from one or more consumer reporting agencies, for the purpose of evaluating you for employment, and, if the undersigned is already employed by this company, for purposes of promotion, reassignment, or retention as an employee. The name of the Investigative Consumer Reporting Agency conducting this consumer report/investigative consumer report is: DataCheck, Inc., 63 Via Pico Plaza PMB #247, San Clemente, CA 92672, PH: 800-253-3394. Their website address is: www.datacheckinc.com. You many find DataCheck's privacy practices, including whether your personal information will be sent outside of the United States or its territories, and information that complies with California Civil Code subsection 1786.20, on their website under Privacy Policies. You are being given a copy of the "Summary of Your Rights Under the Fair Credit Reporting Act" prepared pursuant to 15 U.S.C. section 181 (g & c). You have the right to request additional disclosures of the nature and scope of the investigation and a statement of your rights.
Electronic Signature*
AUTHORIZATION: I have read and understand the foregoing and hereby authorize this company to obtain one or more consumer reports on me for the purposes described above. I understand that this authorization covers (1) consumer reports obtained in connection with my application for employment and (2) if I am hired or if I am an existing employee, additional consumer reports may be obtained during my tenure. I authorize that a copy of this authorization may be considered as valid as an original
A Summary of your Rights under the Fair Credit Reporting Act
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552. The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552. You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment - or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: • a person has taken adverse action against you because of information in your credit report • you are the victim of identity theft and place a fraud alert in your file • your file contains inaccurate information as a result of fraud • you are on public assistance • you are unemployed but expect to apply for employment within 60 days In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information. You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures. Consumer reporting agencies must correct or delete inaccurate, incomplete or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore. You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-567-8688. You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore. States may enforce the FCRA and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact: 1. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates Consumer Financial Protection Bureau 1700 G Street NW Washington, DC 20552 Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB: Federal Trade Commission: Consumer Response Center - FCRA Washington, DC 20580 1-877-382-4357 2. To the extent not included in item 1 above National Banks, federal savings associations, and federal branches and federal agencies of foreign banks. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 State member banks, branches, and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 Federal Credit Unions. National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street, Alexandria, VA 22314 3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue S.E., Washington, DC 20590 4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E. Street S.W., Washington, DC 20423 5. Creditors Subject to Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor 6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, SW, 8th Floor Washington, DC 20416 7. Brokers and Dealers Securities and Exchange Commission 100 F St NE Washington, DC 20549 8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090 9. Retailers, Finance Companies, and All Other Creditors not listed above. FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357
Personal Information Questionnaire
After you submit your application, you will be directed to a Personal Information Questionnaire. The questionnaire is optional and will not be a part of your application.

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
Submit Submit and Print | Go Back

Search Forms:

Application For Employment

Steps

Step One

Step Two

Additional Information

References

Step Five

Step Six

San Miguel County

Quick Links

Helpful Links