351 Sixth Street, Lorain, Ohio 44052-1770

(440) 244-1192 or 1-800-322-READ

Please type or print. An attached resume will not be considered as having provided the requested information.
Incomplete application(s) will not be considered. Applications will generally be accepted for advertised positions only.
Proof of citizenship or immigration status will be required upon employment.

APPLICATION FOR EMPLOYMENT

PERSONAL
Name:
Today's Date: __________
_____________________________________________________
Last
First
Middle

__________________________
E-mail Address

Present Street Address:

_____________________________________________________
Address
City
State
Zip Code

(_____)________________
Telephone Number

Permanent (Or Mailing Address):

_____________________________________________________
Address
City
State
Zip Code
Are you 18 or older?

Yes
Availability:

(_____)________________
Daytime Telephone Number

For checking prior records, provide other names under which you
are, or were known.

No

___________________________________________________

Full-time

Part-time

Regular Basis

Temporary Basis

Position Applied for: ______________________________________________________________

Employment with the Lorain Public Library System involves irregular shifts, nights and weekends. Are you
able to make arrangements to accommodate irregular work hours?

Yes
Preferred work site(s):

No

Main (Lorain)

Columbia (Columbia Station)

Domonkas (Sheffield Lake)

Have you ever applied to work here before?

Yes

No

South (Lorain)

When? __________

Avon
North Ridgeville

Have you ever been employed here before?

Yes

No

A-6-00 rev.

An Equal Opportunity/Affirmative Action Employer

When? __________

EDUCATION
Name and Location

Major Course
of Study

Total Years

Diploma/Degree

High School:

College:

Graduate School:

Other:

Are you now attending school?

Yes
No
Full-time Part-time

What courses are you taking?_______________________

_______________________________________________

If applying for a Student Aide position, _______________________________________________

are you at least 16 years of age?
Yes
No
_______________________________________________

List other special training related to the position you are seeking, including special courses and/or certificates:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Specify foreign language(s) you know and rate knowledge: Poor, Fair, Good, Fluently
Language
Speak
Read
Write

An Equal Opportunity/Affirmative Action Employer

EMPLOYMENT HISTORY Beginning with your most recent employer, please list your last three (3) employers.
______________________________________________ ________________________________
Name of Employer
Type of Business
______________________________________________ ________________________________
Address
Telephone
_______________________ _______________________________________________________
Name of Supervisor
Reason for Leaving
Dates Employed:
From __________ To __________

May we contact this employer?

Yes

No

Brief description of duties: __________________________________________________________

_______________________________________________________________________________
______________________________________________ ________________________________
Name of Employer
Type of Business
______________________________________________ ________________________________
Address
Telephone
_______________________ _______________________________________________________
Name of Supervisor
Reason for Leaving
Dates Employed:
From __________ To __________

May we contact this employer?

Yes

No

Brief description of duties: __________________________________________________________

________________________________________________________________________________
_______________________________________________ _______________________________
Name of Employer
Type of Business
______________________________________________ ________________________________
Address
Telephone
__________________________ ____________________________________________________
Name of Supervisor
Reason for Leaving
Dates Employed:
From __________ To __________

May we contact this employer?

Yes

No

Brief description of duties: __________________________________________________________

_______________________________________________________________________________
NOTE: Your signature is required on reverse side.
An Equal Opportunity/Affirmative Action Employer

Have you been convicted of a crime(s) within the last seven (7) years?

Yes

No

If yes, give date(s) and the nature of the conviction:

__________
Date

________________________________________________________________
Nature of the conviction

A conviction will not automatically disqualify an applicant for consideration. The Lorain Public Library System will consider the type and seriousness of the crime, the frequency of violations, and the applicant's entire work record.

REFERENCES
Name

Give the name and address of three (3) references, including teachers and guidance
counselors who know your experience, scholarship or ability. (No friends or relatives,
please.) Under "relationship", specify in what capacity this person knows you.

Address

Phone

Occupation

Relationship To You

APPLICANT'S STATEMENT:
I certify that the answers given herein are true and complete to the best of my knowledge, and understand and
agree that any misrepresentation or omission on my application or related papers, or made during any oral interviews,
may result in refusal of employment or shall be considered grounds for dismissal.
I understand that consideration for employment in the position for which I am applying is contingent upon the
results of a reference and background check. I therefore authorize the Lorain Public Library System to investigate all
statements made on my application for employment, and to discuss the results of its investigations with those responsible for hiring. I further authorize the Lorain Public Library System to contact my former employer(s) and any listed references or other persons who can verify information, and I give my consent for former employer(s) and other contacted
persons to respond to questions pertaining to information on this application. Further, I release from liability such former
employer(s) or other persons contacted by and providing information to the Lorain Public Library System.
If separated from employment from the Lorain Public Library System for any reason, I authorize it to furnish any
information to persons seeking my employment references and release from liability it and/or any person giving or
receiving any such information.
I understand that this application is not, and is not intended to be, a contract of employment. I understand, also
that I am required to abide by all rules and regulations of the Lorain Public Library System. I have read, understand and
agree to the above.
_____________________________________________________
APPLICANT'S SIGNATURE

_________________________
DATE SIGNED

IF YOU DO NOT SIGN THIS APPLICATION, IT WILL NOT BE CONSIDERED.

Applicants are considered for employment without regard to race, color, religion,
national origin, age, sex, citizenship, union status, disability or any other legally protected status.
Only United States citizens and aliens authorized to work in the United States are eligible for hire.
The Lorain Public Library System is a Drug-Free, Smoke-Free Workplace.
For Employer's Use Only
Test Results:
Name of test(s): ________________________ Date taken: _____________________ Results: _____________
Name of test(s): ________________________ Date taken: _____________________ Results: _____________
Interview Log:
Interviewed for: _______________ By: __________ Date: __________ Remarks:

______________________

Interviewed for: _______________ By: __________ Date: __________ Remarks:

______________________

Employment Log:
Date employed: _______________ Position: __________________________ Grade/Step: __________________

An Equal Opportunity/Affirmative Action Employer

351 Sixth Street, Lorain, Ohio 44052-1770

(440) 244-1192 or 1-800-322-READ

Affirmative Action Pre-Employment Information Form

Applicants are considered for employment without regard to race, color, religion, national origin,
age, sex, citizenship, union status, disability, or any other legally protected status.
To help us comply with Federal/State equal employment opportunity record keeping, reporting
and other legal requirements, and to ensure that we are achieving our affirmative action goals, we
are requesting your voluntary cooperation in answering the questions below.
Please return the completed form to the Human Resources Manager in the attached envelope
with other application forms. This Affirmative Action Pre-Employment Information Form will be
kept in a confidential file separate from your Application for Employment.
Name _________________________________________________ Date ___________________
Address _______________________________________________________________________
Telephone (____)________________________________________________________________
Position applied for ______________________________________________________________
Self-Inquiry

How did you learn of this position?

Relative

Advertisement

Community Program

Employment Agency

School

Friend

Professional Publication

Other ____________________________________________

Is anyone on the Library staff your relative? No Yes Name/Relationship: _____________

Your Race/Ethnic Group: White

Black

Hispanic

Native American/Eskimo Asian/Pacific Islander

Sex: Male

Female

Age: Under 18 18-30

Veteran

A-6a-00 rev.

30-40

40-50

50-60

60-70

Disabled

An Equal Opportunity/Affirmative Action Employer

Over 70

351 Sixth Street, Lorain, Ohio 44052-1770

(440) 244-1192 or 1-800-322-READ

Addendum to Application Form

Notice:
This is to inform you that as part of our procedure for processing your employment application, and during employment, The Lorain Public Library System may from time to time obtain from a credit-reporting
agency a consumer report containing financial and other information about you.
The Lorain Public Library System will not obtain such a report without your signed authorization. This
disclosure and authorization are continuing in nature.
The Lorain Public Library System complies with the Fair Credit Reporting Act, which provides consumers with rights regarding consumer reports and which places specific obligations on employers
using credit reports.

AUTHORIZATION FOR EMPLOYER TO OBTAIN A CONSUMER REPORT

I authorize the Lorain Public Library System to order a Consumer Report containing financial
and other information about me from a consumer reporting agency as part of the Lorain Public
Library System's investigation into my application for employment and at anytime during my
employment with the Lorain Public Library System.
Signature: ___________________________________________________________________
Date: _______________________________________________________________________

DISCLOSURE STATEMENT
I hereby acknowledge that I have read the above disclosure statement and have understood it.
Signature: ___________________________________________________________________
Date: _______________________________________________________________________
An Equal Opportunity/Affirmative Action Employer
A-6b-00 rev.