It is KHCPL’s policy that equal employment opportunities be available to all persons without regard to race, sex, age, sexual orientation, marital status, family status, veteran status, ancestry, color, religion, creed, national origin, citizenship status, genetic information, participation in military service or disability or other category protected by federal, state or local law. This policy applies to all employees and applicants for employment and to all phases of employment including hiring, promotion, demotion, treatment during employment, rates of pay or other forms of compensation, and termination of employment.

The Library will comply with its obligation to provide reasonable accommodation to qualified individuals with disabilities.

Date

Contact Information

First Name

Last Name

Middle Name

Daytime Phone

Cell Phone

Email Address

Street Address (Mailing address, including apt/lot no.)
City		State		Zip Code

Position Information

Position Applying For
Have you ever been employed here before? No Yes		If Yes, Dates
Are you 18 years of age or older? No Yes		If No, State Age
Are you legally eligible to work in the United States? No Yes
List any relative or household member who is employed by the library, who is a library volunteer, or a member of the Library Board of Trustees.

Education

School / Location

Years Completed

Degree Earned

Major / Minor

High School

9 10 11 12

College

1 2 3 4

Post-Graduate

1 2 3 4

Describe any training, continuing education or skills which might be relevant to the position being applied for

Employment Experience

Starting with most recent or current job, list all past employment for at least five years. (May include volunteer activities.)

Employer #1
Employer		Phone
Address
Job Title		Supervisor
Employed From		To
Wage or Salary		Reason for Leaving
Work Performed

Employer #2
Employer		Phone
Address
Job Title		Supervisor
Employed From		To
Wage or Salary		Reason for Leaving
Work Performed

Employer #3
Employer		Phone
Address
Job Title		Supervisor
Employed From		To
Wage or Salary		Reason for Leaving
Work Performed

Employer #4
Employer		Phone
Address
Job Title		Supervisor
Employed From		To
Wage or Salary		Reason for Leaving
Work Performed

Employer #5
Employer		Phone
Address
Job Title		Supervisor
Employed From		To
Wage or Salary		Reason for Leaving
Work Performed

References

NAME	ADDRESS	PHONE NUMBER	OCCUPATION

Availability

Listed below are the library's regular working hours. Would you be able to work all of these listed hours?

Yes
No

If no, please list days and hours which you will not be available to work:

You may be required to perform the job duties listed below:

Lift, bend, squat and stretch while working with library materials.
Sort and shelve books and other materials in alphabetical or numerical order.
Straighten up shelves, tables and other areas of the library.
Shift library materials on shelves or from one shelf to another.
Lift library materials out of large bins.
Carry materials or push cart of materials from one area to another.
Work with the public.
Answer telephones and direct calls to appropriate locations.
Work with computers.

Application Statement

All information on this application is true, correct and complete to the best of my knowledge. False, misleading or omitted information may result in refusal to hire, a revocation of an offer or employment, or subsequent termination of employment.

All statements contained in the application may be investigated and I acknowledge that inquiries may include information as to character, general reputation, personal characteristics, work performance and workplace conduct.

I authorize my previous employers, schools or persons named as references to give any information regarding my employment or educational record. I agree to hold harmless any persons, firms, institutions or agencies providing such information to an authorized representative of the library on the basis of their disclosures.

If the position requires driving of any library vehicle and if I am offered employment, I understand that the library will obtain a copy of my driving record from the Indiana Department of Motor Vehicles. If I have recently resided in another state, my driving record will be obtained from the government agency responsible with providing the information in that state.

If I am offered employment, I will be required to provide proof of identity that I am either a U. S. citizen or alien authorized to work in the United States in the position of employment.

If I am offered employment, I will give my consent to the Kokomo-Howard County Public Library to obtain a urine specimen and to conduct laboratory analysis of said specimen for purposes of detecting illegal, controlled or unauthorized substances. I understand that if by such analysis it is determined that any illegal, controlled or unauthorized substance is present in my system, the offer for employment will be withdrawn.

I understand that this application is not intended to be a contract of employment, that any resulting employment is for no fixed period of time, and that the employment relationship may be terminated at any time, either by myself or by the library.

I understand that no individual other than a specified library administrator has the authority to enter into any agreement for any specific period of time or to make an agreement contrary to the statements above and that any such agreement must be in writing to be binding.