ISU Extension and Outreach - Madison County
EMPLOYMENT APPLICATION for EXECUTIVE DIRECTOR
An Equal Opportunity Employer
1. Full Name
Last
2. Telephone Number(s)
First
( )
-
Middle
( )
Area Code/Primary/Home number
-
Area Code/Alternate number
3. Address
Street/P. O. Box/Apt #
City
State
Zip
(Yes/No)
4. Are you 18 years of age or older?
(Yes/No)
5. Are you legally authorized to work in the United States?
6. Have you ever been convicted of a felony?
(Yes/No)
If, yes,* for what, where, and when:
*A criminal conviction is not an absolute bar to employment but will only be considered
in relationship to specific job requirements.
Date Available for Employment
POSITION(S) FOR WHICH YOU ARE APPLYING
Position - One title per line
1.
2.
3.
Each job position has minimum education, experience, and/or ability requirements. It is very important that all of your education and
work experience (paid, volunteer or self-employment, such as farming) be listed. Use complete dates (month and year), and one figure
for the number of hours worked per week when reporting work experience.
EDUCATIONAL DATA
High School Graduate or Equivalent (GED)?
(Yes/No)
You may be required to provide a transcript
Name and location of college, university, vocational/technical
schools
(Most Recent First)
a.
b.
c.
From
Mo
To
Yr
Mo
Degree
Yr
Major or Course Title
AA, AS, BA, BS,
MA, MS, CEU’s
EMPLOYMENT DATA
A.
B.
C.
D.
If you had more than one position with the same employer, list each separately.
If a job was part time, list the average number of hours worked per week.
When describing a job, list 3 or 4 major tasks performed and the approximate percentage of time spent on each task.
Volunteer work experience will be evaluated in the same manner as paid employment and should be entered the same.
1. EMPLOYMENT HISTORY (Current )
Employer
Employer's Address
Employer’s Phone Number
Your Title
to
Employed
/
/
from
month/year
month/year
Reason for leaving
List all machines/equipment/software used on the job:
Type of Business
May we contact this employer?
Supervisor's Name
Average hours per week employed
Amount paid per hour or salary:
Duties: (Be Specific)
(1.)
%
(2.)
%
(3.)
%
(4.)
%
2 EMPLOYMENT HISTORY
Employer
Employer's Address
Employer’s Phone Number
Your Title
to
Employed
/
/
from
month/year
month/year
Reason for leaving
List all machines/equipment/software used on the job:
Amount paid per hour or salary:
Duties: (Be Specific)
(1.)
%
(2.)
%
(3.)
%
(4.)
%
Type of Business
May we contact this employer?
Supervisor's Name
Average hours per week employed
3. EMPLOYMENT HISTORY
Employer
Employer's Address
Employer’s Phone Number
Your Title
to
Employed
/
/
from
month/year
month/year
Reason for leaving
List all machines/equipment/software used on the job:
Type of Business
May we contact this employer?
Supervisor's Name
Average hours per week employed
Amount paid per hour or salary:
Duties: (Be Specific)
(1.)
%
(2.)
%
(3.)
%
(4.)
%
4. EMPLOYMENT HISTORY
Employer
Employer's Address
Employer’s Phone Number
Your Title
to
Employed
/
/
from
month/year
month/year
Reason for leaving
List all machines/equipment/software used on the job:
Amount paid per hour or salary:
Duties: (Be Specific)
(1.)
%
(2.)
%
(3.)
%
(4.)
%
Type of Business
May we contact this employer?
Supervisor's Name
Average hours per week employed
Personal/Professional References Do not include family members
Name
Phone Number
Best Time to Call
Occupation
COMMENTS: State any additional information you feel may be helpful to us in considering your application.
SUPPLEMENTAL QUESTIONS (required):
1. Please describe your experience and knowledge of Iowa State University Extension and Outreach.
2. Please describe your experience(s) in volunteering and managing volunteers.
3. Please briefly describe your experience in supervising staff and performance in human resource functions.
4. Please briefly describe your experience in public relations.
5. If you have a teacher’s certificate, please provide license # and issuing state.
6. Please briefly describe your experience in formal and non-formal teaching.
7. Please briefly describe your knowledge and skills in community development and economic development.
8. Please briefly describe your experience in developing social marketing channels.
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.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship
within 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 a 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 on the employer.
/
Applicant’s Signature (may be typed if submitting electronically)
/
Date
… and justice for all
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and
where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of
an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative
means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at 202-720-2600 (voice and TDD). To
file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue SW, Washington, DC 20250-9410, or call 800-7953272 (voice) or 202-720-6382 (TDD). USDA is an equal opportunity provider and employer.