Job Application

Griggs County Public Library

Your completed application may be submitted to the following address by regular mail, email or by bringing it to the library:

Griggs County Board of Directors
Care of: Griggs County Public Library
902 Burrel Ave SE
PO Box 546
Cooperstown, ND 58425

To be considered for a position with Griggs County Public Library, please print or type your responses on the following Application for Employment form. All applicable sections must be completed. Please remember to sign and date the form. Please submit with a letter of interest and other pertinent materials.

Personal Information:

Name: First                  MI                     Last
Address                                                         City                                    State  Zip
Home/Cell Phone
Do you have the legal right to work in the US.                     _____Yes      _____No
Are you under 18 years of age _________Yes _______No
Have you ever used another name that would affect employment and education reference verification?
 If so please list here:

Employment Desired

Position desiredDate available for work
State any schedule limitations to working at the library:
Have you ever applied to this company beforeWhen

Education: (Please include non tradition education if applicable.)

Level of EducationDegree/DiplomaArea of SpecializationCompleted or In Progress
High School   
 Other (Vocational, Tech, etc.)   

Do you plan further education ____Yes ___No
Do you have a start date for your courses:_______________________________________
Type of course/program:

The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 but less than 70 years of age.

Former Employers

 Start with most recent employment

May we contact the employers listed below?  ______ Yes  _____No
Indicate those you do not wish us to contact:

Did you work for any of the employers listed under a different name  _____Yes  ____ No

If yes, indicate employer and the name you used:

Employer:                                       Supervisor: Phone:
AddressEmployed (month and year)   From                       To
Job TitleTotal Hours Worked                     _____week   ______month
Describe your dutiesReason for leaving
Employer:                                        Supervisor:Phone:
AddressEmployed (month and year)   From                       To
Job TitleTotal Hours Worked                     _____week   ______month
Describe your dutiesReason for leaving
Employer:                                        Supervisor:Phone:
AddressEmployed (month and year)     From                       To
Job TitleTotal Hours Worked                     _____week   ______month
Describe your dutiesReason for leaving

If you wish to include other employers, please use an additional page.

Three Work Related References:

Name Phone Address OccupationTime Known

If you wish to include other references, please use an additional page.

Physical Record:

Do you have any physical limitations that preclude you from performing any work for which you are considered:  

Yes __________  No _____________

A staff member is required to: see, talk and hear; sit, stand and walk; twist and bend; use hands to finger, handle or feel; reach with hands and arms; climb and/or balance. Staff members must occasionally lift and/or move objects or materials weighing up to 40 pounds and are required to push or pull carts of books and other materials. Specific vision abilities include close vision.

If yes, what can be done to accommodate your limitation?  Please describe:

Do you have a valid driver’s license and access to a working vehicle  Yes____  No ___.

Additional Information

Use this space to list special, pertinent skills, abilities, accomplishments, and for any comments or information that may be helpful in reviewing your qualifications. If more space is needed. please use an additional page.

Applicant Read and Sign

I certify that the facts contained in this application are true and complete to best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.  I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.

Date: _______________________ Signature: _________________________________

Do not write below this line

Interviewed by: ___________________________________ Date: __________________

Hired:  Yes       No

Position: _____________________________

Salary: _______________________________   Date reporting to work: ______________