APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION
As an applicant for a position with Walla Walla County, I hereby authorize any employers or supervisors, educational institutions, personal references and/or other persons to release information about my work and education history for use in determining my qualifications for this position. I understand, agree, and authorize that a copy or facsimile of this form to be as valid as the original.
You may release or verify the following items:
1. Dates of employment.
2. Positions held when started and left.
3. Performance level, duties, responsibilities, strong and weak points.
4. My attendance habits (excluding workers’ compensation, pregnancy, and other protected absences).
5. My relationship with co-workers and supervisors.
6. My attitude toward work (cooperative? positive? etc.).
7. Reason for leaving.
8. Eligibility for rehire.
9. Whether I have had outbursts of temper, threatened, provoked fights with or assaulted others, engaged in hostile or violent behavior, have a criminal record or any traits that would present security or safety issues for others.
10. Any other relevant information regarding my performance, skills, ability, suitability for employment sought, etc.
Educational Institutions:
1. Years of Attendance.
2. Degree(s) Attained.
3. Grade Point Average; and
4. Transcript.
I understand my right to request access to any public records relating to me pursuant to Title 5 of the United States Code, Section 552 et seq., the Privacy Act of 1974, the Freedom of Information Act, and Revised Code of Washington (RCW) 42.17 et seq., and specifically waive those rights understanding that the information furnished will be used by Walla Walla County and/or its agencies or departments in conjunction with employment procedures. I will make no attempt to gain access to the information provided by you to Walla Walla County and/or its agencies or departments in conjunction with this employment process and hereby expressly waive any rights I may have to request the disclosure or information provided by you to Walla Walla County and/or its agencies or departments in conjunction with employment procedures.
All former employers who provide such information are indemnified and released from liability arising from such disclosures.
APPLICANT CERTIFICATION & AGREEMENT: (Read carefully before signing)
I certify that this information contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I understand that if employed, misleading or falsified statements on this application may be considered cause for dismissal.
Equal Employment Opportunity
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.
The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.
Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender
Male
Female
I choose not to disclose this information
Ethnicity
Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race)
Not Hispanic or Latino (if not Hispanic or Latino, please address race below)
I choose not to disclose this information
Race (do not respond if you selected "Hispanic or Latino" above)
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the black racial groups of Africa
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above five races
I choose not to disclose this information
Protected Veterans
The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran
Disabled Veteran
A "disabled veteran" is one of the following:
Recently Separated Veteran
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
Active Duty Wartime or Campaign Badge Veteran
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
Armed Forces Service Medal Veteran
An "armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
I am not a Protected Veteran
I choose not to disclose this information
Disability Status
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Yes I have a disability (or previously had one)
No I don't have a disability
