Step 1 of 4 25% Name(Required) First Middle Last Email(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Daytime Telephone NumberEvening Telephone NumberPosition(s) Applied ForCurrent Department Or UnitHave you ever been discharged or forced to resign from any job? If yes, explain:Are you capable of performing the essential functions required for the position for which you are applying with or without an accommodation? Yes No Are you now employed? Yes No May we contact your present employer? If no, explain:Can you travel if position requires it? Yes No Do you have transportation available if your job requires travel? Yes No Date Available For Work MM slash DD slash YYYY Are you available to work: Full Time Part Time Temporary Minimum Starting Salary You Will AcceptFrom what source did you learn of this position? Educational RecordName of SchoolLocationMajor or SpecializationDegree/Certification obtainedFrom MM slash DD slash YYYY To MM slash DD slash YYYY Total HoursDegree/Diploma Graduated G.E.D. YearAdd another? No Yes Name of SchoolLocationMajor or SpecializationDegree/Certification obtainedFrom MM slash DD slash YYYY To MM slash DD slash YYYY Total HoursDegree/Diploma Graduated G.E.D. Year YearAdd another? No Yes Name of SchoolLocationMajor or SpecializationDegree/Certification obtainedFrom MM slash DD slash YYYY To MM slash DD slash YYYY Total HoursDegree/Diploma Gruaduated G.E.D. Year Year Employment RecordName of EmployerPhoneAddress (City & State) City State / Province / Region Date Employed MM slash DD slash YYYY Date Separated MM slash DD slash YYYY Job TitleEnding Salary ($)Number of Months (Full time)Number of Months (Part time)Name and Title of SupervisorReason for LeavingBrief Description of your ResponsibilitesAdd more? No Yes This field is hidden when viewing the formName of EmployerPhoneAddress (City & State) City State / Province / Region Date Employed MM slash DD slash YYYY Date Separated MM slash DD slash YYYY Job TitleEnding Salary ($)Number of Months (Full time)Number of Months (Part time)Name and Title of SupervisorReason for LeavingBrief Description of your ResponsibilitesName of EmployerPhoneAddress (City & State) City State / Province / Region Date Employed MM slash DD slash YYYY Date Separated MM slash DD slash YYYY Job TitleEnding Salary ($)Number of Months (Full time)Number of Months (Part time)Name and Title of SupervisorReason for LeavingBrief Description of your ResponsibilitesName of EmployerPhoneAddress (City & State) City State / Province / Region Date Employed MM slash DD slash YYYY Date Separated MM slash DD slash YYYY Job TitleEnding Salary ($)Number of Months (Full time)Number of Months (Part time)Name and Title of SupervisorReason for LeavingBrief Description of your ResponsibilitesAdditional RemarksList any professional organizations or groups which you belong:If you are currently certified, registered, or licensed to practice your profession of occupation, give:Name of Association or licensing authorityCertification registration or license numberGive names of three persons, preferably business or professional, as references(Not relatives or employers)Name First Last Home or Business Address Street Address City State / Province / Region Occupation or BusinessTelephone NumberName First Last Home or Business Address Street Address City State / Province / Region Occupation or BusinessTelephone NumberName First Last Home or Business Address Street Address City State / Province / Region Occupation or BusinessTelephone NumberProvide any other information you believe may be pertinent to the position applied for.Such as scholastic honors, volunteer work, membership in civic organizations, publications, special training not included above, special skills, etc. In case of emergency, contact:Name First Last Address Street Address City State / Province / Region Occupation or BusinessPhoneName First Last Address Street Address City State / Province / Region Occupation or BusinessPhoneThe Douglas County Public Health Services Group, Inc. requires that all applicants for employment complete and sign an Application for Employment. The Center relies upon the accuracy of information contained in the employment application, as well as the accuracy of other data presented throughout the hiring process and employment. Any misrepresentation, falsifications, or material omissions in any of this information or data may result in the exclusion of the individual from further consideration for employment or, if the person has been hired, termination of employment. Therefore, I certify that the answers I have made to each and all of the foregoing are true and correct to the best of my knowledge and belief. Date MM slash DD slash YYYY SignatureCommentsThis field is for validation purposes and should be left unchanged. Δ
