McHenry County, IL

 Elected position or board/commission applying for:

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Elected position or board/commission applying for:

How did you become aware of this available position?

How did you become aware of this available position?

Applicant Information

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Applicant Information

First Name:

Middle Name:

Last Name:

Address:

City:

State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Telephone:ext.

Email:

Have you worked for McHenry County before?

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Have you worked for McHenry County before?

Yes

No

If yes, give date(s):

If yes, give date(s):

Do you have any relatives currently employed by McHenry County or any political sub-division thereof?

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Do you have any relatives currently employed by McHenry County or any political sub-division thereof?

Yes

No

If yes, please provide name(s):

If yes, please provide name(s):

Have you ever been convicted of or charged with a felony or misdemeanor? (A conviction will not automatically disqualify you from an appointment; exclude minor traffic violations.)

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Have you ever been convicted of or charged with a felony or misdemeanor? (A conviction will not automatically disqualify you from an appointment; exclude minor traffic violations.)

Yes

No

If yes, please explain:

If yes, please explain:

Are there any felony/misdemeanor charges pending against you?

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Are there any felony/misdemeanor charges pending against you?

Yes

No

If yes, please explain:

If yes, please explain:

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Employment History

Your work experience is an important factor in evaluating your qualifications. Please list your current employer.

Employment History Your work experience is an important factor in evaluating your qualifications. Please list your current employer.

Name of Employer:

Type of Business:

Telephone:ext.

Employer's Address:

City:

State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Name of Supervisor:

May we contact this employer?

May we contact this employer?

Yes

No

Dates of Employment:

Dates of Employment:

From:

To:

Job title & description of duties performed:

Job title & description of duties performed:

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Public/Civic Leadership Information

What do you believe is the role of the elected office or board/commission for which you are applying?

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Public/Civic Leadership Information What do you believe is the role of the elected office or board/commission for which you are applying?

Do you or any of your close family or business connections make use of services provided by, or connected with, the elected office or board/commission for which you are applying?

 *

Do you or any of your close family or business connections make use of services provided by, or connected with, the elected office or board/commission for which you are applying?

Yes

No

If yes, please explain:

If yes, please explain:

Do you or any of your close family or business connections serve in any elected office, on any board/commission, or with any organization which has or may have any connection or relationship with the elected office or board/commission for which you are applying?

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Do you or any of your close family or business connections serve in any elected office, on any board/commission, or with any organization which has or may have any connection or relationship with the elected office or board/commission for which you are applying?

Yes

No

If yes, please explain:

If yes, please explain:

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References

Please give the names of three persons, not related to you, whom you have known for over one year.

Reference 1

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Reference 1

Name:

Address:

Telephone:

Occupation:

Years Known:

Reference 2

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Reference 2

Name:

Address:

Telephone:

Occupation:

Years Known:

Reference 3

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Reference 3

Name:

Address:

Telephone:

Occupation:

Years Known:

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Education & Life Experience

Are you currently or have you previously served as an elected official, served in a government commission, or private organization?

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Education & Life Experience Are you currently or have you previously served as an elected official, served in a government commission, or private organization?

Yes

No

If yes, please explain:

If yes, please explain:

What education, training, or experience do you believe would assist you with serving the elected office or board/commission for which you are applying?

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What education, training, or experience do you believe would assist you with serving the elected office or board/commission for which you are applying?

What do you hope to accomplish as a result of serving the elected office or board/commission for which you are applying?

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What do you hope to accomplish as a result of serving the elected office or board/commission for which you are applying?

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Certification & Release - Read Carefully

I certify that the answers and information given by me in this application are true, correct and complete without qualification. I understand the County has the right to refuse to appoint me or immediately discharge me, at any time if it discovers I have provided incomplete, untrue, or misleading answers or information in this application or on any other documents or forms submitted at any time during my employment.

I authorize the County and its agents, to verify the answers and information given by me in this application and to make any investigation of my background deemed necessary. I authorize former employers, law enforcement organizations, educational institutions, and any other third party contacted by the County or its representatives, to release to the County or its agents information which may be used to verify information in this application.

I understand that any position I am appointed to may require me to complete a Statement of Economic Interest and the McHenry County Addendum to the Statement of Economic Interest to be filed with the McHenry County Clerk.

 

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By checking this box, I acknowledge that I have read and agree to the above statements.

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