Application for Employment

Application for Employment
Date:
Name:
Address:
Henderson County Health Department
PO Box 220
208 West Elm Street
Gladstone, Illinois 61437
Phone: 309-627-2812
Fax: 309-627-2793
City:
State
Alabama
Zip/Postal Code:
SS Number:
Home Phone:
Cell Phone:
Positions Applied for:
per
Salary Desired:
Hour
Year
Days Available to Work:
Mon
Check Box
Tues
Check Box
Wed
Check Box
Thurs
Check Box
Fri
Check Box
Sat
Check Box
Sun
Check Box
Full-Time
part-time
Date Available for Work:
Do you have a lawful right to work in the
United States?
Please Select
Have you worked here before
Please Select
How did you hear about us?
Please Select
Full or part-time
Education
Type of School
Name of School and Complete Mailing Address
No. Years Completed
Did You Graduate?
High School
College Bus. or
Trade School
Professional School
Other
Note: You are not obligated to disclose sealed or expunged
records of conviction or arrest
Have you ever been convicted of a felony:
Select:
If yes, please explain below:
Do you have a drivers license?
yes
no
State of issue:
Have you had any accidents in the past 3 years?
yes
no
How many?
Do you had any moving violations in the past 3 years?
yes
no
How many?
Continue on the next page
Current Employer:
Name of Employer:
Name of supervisor:
Dates of employment:
From:
To:
From:
To:
Salary:
Complete Address:
Phone #:
Job Title:
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you have worked at this company:
May we contact your employer:
yes
no
Previous Employment (1):
Name of Employer:
Name of last supervisor:
Dates of employment:
From:
To:
From:
To:
Salary:
Complete Address:
Phone #:
Last job title:
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:
May we contact your employer:
yes
no
Continue on the next page
Previous Employment (2):
Name of Employer:
Name of last supervisor:
Dates of employment:
From:
To:
From:
To:
Salary:
Complete Address:
Phone #:
Last job title:
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:
May we contact your employer:
yes
no
Skills:
Typing:
Computer:
PC
Mac
Both
Applications (list all that apply):
Please answer the questions below relating to essential job functions:
1.) Can you get to work on time?
Select yes or no
2.) Can you communicate effectively with others in speech and in writing?
3.) Lift 20-40 pounds repeatedly?
Select yes or no
4.) Work after hours, weekends, or holidays if requested?
Select yes or no
5.) Would you be available to assist with other duties
during a public health emergency?
Select yes or no
Select yes or no
BY CLICKING THE "AGREE AND SEND FORM" BOX BELOW, YOU AGREE TO THE FOLLOWING:
NOTHING ON THIS FORM SHALL BE CONSTRUED AS A GUARANTEE OF EMPLOYMENT OR
PROMISE OF CONTINUED EMPLOYMENT. THIS INFORMATION IS NOT TO BE REGARDED AS A
CONTRACT AND DOES NOT GUARANTEE SPECIFIC BENEFITS.
THE HENDERSON COUNTY HEALTH DEPARTMENT IS AN “AT WILL” EMPLOYER. I UNDERSTAND AND AGREE
THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD, AND REGARDLESS OF THE DATE OF PAYMENT
OF MY WAGES OR SALARY, I MAY BE TERMINATED AT ANY TIME WITH OR WITHOUT CAUSE OR PRIOR NOTICE. I
FURTHER UNDERSTAND THAT ONLY THE HENDERSON COUNTY HEALTH DEPARTMENT ADMINISTRATOR,
HUMAN RESOURCE DIRECTOR, OR PERSON SPECIFICALLY DESIGNATED BY THE ADMINISTRATOR HAS THE
AUTHORITY TO CREATE OR ENTER INTO ANY AGREEMENT ON BEHALF OF THE HENDERSON COUNTY HEALTH
DEPARTMENT.
AUTHORIZATION
I AUTHORIZE THE HENDERSON COUNTY HEALTH DEPARTMENT TO INVESTIGATE ALL STATEMENTS CONTAINED
IN THIS APPLICATION AND AUTHORIZE ALL REFERENCES LISTED IN THE APPLICATION TO GIVE THE
HENDERSON COUNTY HEALTH DEPARTMENT ANY AND ALL INFORMATION CONCERNING MY PREVIOUS
EMPLOYMENT AND ANY PERTINENT INFORMATION, PERSONAL, OR OTHERWISE.
I RELEASE ALL PARTIES FROM LIABILITY FOR ANY DAMAGES THAT MAY RESULT FROM SUCH AN
INVESTIGATION AND FROM THE REFERENCES FURNISHING INFORMATION TO THE HENDERSON COUNTY
HEALTH DEPARTMENT.
I CERTIFY THAT ALL FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE AND I UNDERSTAND THAT OMISSION OR MISREPRESENTATION OF FACTS MAY BE GROUNDS FOR
REJECTION OF THE APPLICATION OR FOR DISMISSAL FROM EMPLOYMENT IF SUBSEQUENTLY DISCOVERED.
EQUAL EMPLOYMENT OPPORTUNITY STATEMENT
THE HENDERSON COUNTY HEALTH DEPARTMENT (HCHD) PROHIBITS DISCRIMINATION IN EMPLOYMENT,
EDUCATIONAL PROGRAMS, AND ACTIVITIES ON THE BASIS OF RACE, NATIONAL ORIGIN, COLOR, CREED,
RELIGION, SEX, AGE, DISABILITY, PREGNANCY, VETERAN STATUS, SEXUAL ORIENTATION, GENDER IDENTITY,
OR ASSOCIATIONAL PREFERENCE. THE HCHD ALSO AFFIRMS ITS COMMITMENT TO PROVIDING EQUAL
OPPORTUNITIES AND EQUAL ACCESS TO HEALTH DEPARTMENT FACILITIES. FOR ADDITIONAL INFORMATION
CONTACT THE OFFICE OF HUMAN RESOURCES AT (309) 627-2812, EXT. 241.
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