Cheshire County Department of Corrections


825 Marlboro Road

Keene, NH 03431 



An equal opportunity employer




     Today's date   







     Last name                              First name                       Middle 



     Address                                 City/town                         State        Zip Code



     Social Security number          Home Phone                      Business Phone



     Email Address  




Employment History


     Have you been previously employed by Cheshire County?    Yes    No


     If Yes, when and where  


     Position applied for                Full time    Part time    Temp


     Are you available to work rotating shifts?                          


    Are you eligible for employment in the United States?         


    Are you 21 years of age?   





    College                  Degree 


    High School           Diploma        G.E.D 



    Special training, skills, certifications, licenses, languages




Employment History

Beginning with current position


     Company Name                          Address                                                       Phone number



    Employment Dates                                Starting Pay               Ending Pay




    Name of Supervisor                      Reason for leaving





    Company Name                           Address                                                         Phone number



    Employment Dates                                   Starting Pay                Ending Pay




     Name of Supervisor                        Reason for leaving




     Company Name                            Address                                                      Phone number



    Employment Dates                                   Starting Pay               Ending Pay




    Name of Supervisor                           Reason for leaving




                                                                                      Complete if you have ever been in the armed forces



    Branch        Period of active duty     From    To 


    Rank at discharge                       Type of discharge 


    Date of discharge       Duties in brief 


    May we contact the employers listed above?    Yes    No         


    If, No  please explain            




    Personal References



     Name                                          Address                                                 Phone                      Occupation





     Name                                          Address                                                 Phone                      Occupation




     Name                                          Address                                                 Phone                      Occupation




 I declare the information in this employment application provided by me is true, correct, and complete to the best of my knowledge.  I understand that if employed any misstatement or omission of facts in this application shall be considered cause for dismissal.  I authorize the Cheshire County Department of Corrections to make appropriate reference, financial, and or criminal checks for verification of given information.




I also am aware that this application is going to the Cheshire County Dept. of Corrections in New Hampshire.




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