Sussex County Assessment Referees Application Form

Name *

Address *

City *

State *

ZIP Code *

Home Phone

Cell Phone

Work Phone

Email *

Are you a U.S. citizen? *

Yes

Employment History

Name of Employer

Address

Phone #

Name of last supervisor

Last job title

Dates of employment

From:

To:

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company

Name of Employer

Address

Phone #

Name of last supervisor

Last job title

Dates of employment:

From:

To:

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company

References

Name

Address

Telephone

Name

Address

Telephone

Name

Address

Telephone

Service History

Dates of military service

From:

To:

Branch

Support Documents

Use these links to attach supporting documents such as a resume, CV, professional license, etc.

Document

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Document

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Document

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Please provide a narrative of your background and experience and why you want to serve as a referee for the reassessment appeals process. *

Appellants will be able to schedule a time with a Referee from 8:30am to 4:30pm. A referee will be paid by the hour. However, it is expected that the Referee is readily available Monday through Friday 8:30am-4:30pm to take appointments. It is expected that the term of this assignment will begin February 17th and go through a time in which all appeals have seen a referee. This assignment could extend through May 31st.

Are you able to fulfill this requirement and attend the necessary meetings? *

Yes

Yes, with the accommodations described below

Accommodations Required *

As a referee, the potential for a conflict of interest with an application is always present. Do you have any known or anticipated conflicts of interest that may present themselves as a Referee that would affect your ability to serve? *

Yes

If yes, please explain.

INFORMATION FOR APPLICANTS

Applications should be submitted online. Any application that is received unsigned, incomplete, or after the closing date specified, may be rejected.

Sussex County is an Equal Opportunity Employer and does not discriminate on the basis of race, marital status, genetic information, color, age, religion, sex (including pregnancy), sexual orientation, gender identity, national origin or disability. It is our intention that all qualified applicants are to be given equal opportunity and that selection decisions are based on job‐related information.

Direct Deposit: Direct Deposit with a financial institution of your choice is mandatory for all appointed officials.

AUTHORIZATION FOR CONSENT AND RELEASE

I hereby certify that the answers given by me to the foregoing questions and the statements made by me are full and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts in this application or any supplements thereto is cause for rejection of my application. I understand that if I am selected by Sussex County Government, the County shall require verification of my identity and eligibility for employment in the United States. I understand that I voluntarily authorize my former employers, schools, and persons named herein to give information regarding me. I hereby release said organization from any liability or claim whatsoever for issuing this information. I also permit the County to conduct a criminal investigation of my background if required for the position for which I am applying.

Applicant Name *

Date *

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Sussex County Assessment Referees Application Form

INFORMATION FOR APPLICANTS

AUTHORIZATION FOR CONSENT AND RELEASE