2. Clay County Public Health Center Job Application

   Clay County Public Health Center requires a pre-employment Drug, Alcohol & Tobacco/Nicotine Screening. We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application in used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and /or interview process should notify a representative of the Health Center.

6. First Name
7. Last Name
9. Position applying for or type of work desired
10. Home phone number
12. Address (City & State)
13. Email
15. Hours of employment desired

    1. Full-time
    2. Part-time
    3. PRN
16. Date you will be available to start work
17. Desired pay/ salary
19. Are you able to meet the attendance requirements of the job you are applying for?

    1. Yes
    2. No
20. Can you perform the duties of the job you are applying for?

    1. Yes
    2. No
21. Do you have any objection to working overtime, if necessary?

    1. Yes
    2. No
23. Can you travel if required by this position?

    1. Yes
    2. No
24. Have you ever been previously employed by our organization?

    1. Yes
    2. No
26. Do you have relatives, guardians and/or wards presently employed at Clay County Public Health Center?

    1. Yes
    2. No
27. If yes, list name and relationship
28. If you are under 18, can you furnish a work permit if it is required?

    1. Yes
    2. No
30. If necessary for the job, can you provide a valid driver's license and/or proof of auto insurance?

    1. Yes
    2. No
31. Can you submit proof of legal employment authorization and identity?

    1. Yes
    2. No
33. Are you authorized to work lawfully in the United States?

    1. Yes
    2. No
34. Will you now or in the future require our company to commence immigration sponsorship to employ you?

    1. Yes
    2. No
36. Have you used tobacco/nicotine containing products or controlled substances "drugs" in the last six (6) months?

    (A criminal record or conviction will not automatically bar employment, but will be considered as it relates to the position for which you are applying).

    1. Yes
    2. No
37. Have you pled "guilty" or "no contest" to, or been convicted of a crime within the last 7 years, or do you have any pending criminal charges at this time?

    1. Yes
    2. No
39. If yes, please explain
40. How were you referred to us?
44. Employment History
    Please provide all employment information for your past four (4) employers, starting with the most recent.
46. Employer
47. Position held
49. City & State
50. Phone number
52. Immediate supervisor and title
53. Dates employed
55. Pay/Salary
56. Reason for leaving
58. Job summary
59. May we contact your present employer?

    1. Yes
    2. No
63. Employer
64. Position held
66. City & State
67. Phone number
69. Immediate supervisor and title
70. Date employed
72. Pay/Salary
73. Reason for leaving
75. Job summary
79. Employer
80. Position held
82. City & State
83. Phone number
85. Immediate supervisor and title
86. Dates employed
88. Pay/Salary
89. Reason for leaving
91. Job summary
95. Employer
96. Position held
98. City & State
99. Phone number
101. Immediate supervisor and title
102. Date employed
104. Pay/Salary
105. Reason for leaving
107. Job summary
111. If an employment was under a different name, indicate name
115. Summarize any employment gaps, job related training skills, licenses, certificates, military service or other qualifications
119. High School
121. Name
122. City & State
123. Completed?

     1. Not completed
     2. GED
     3. Diploma
127. College
129. Name
130. City & State
132. Completed?

     1. Not completed
     2. Graduated, degree earned
133. Number of years completed
134. Degree earned
136. Course of study
140. Graduate degree
142. Name
143. City & State
145. Completed?

     1. Not completed
     2. Graduated, degree earned
146. Number of years completed
147. Degree earned
149. Course of study
153. Technical Training
155. Name
156. City & State
158. Completed?

     1. Not completed
     2. Graduated, degree earned
159. Number of years completed
160. Degree earned
162. Course of study
166. Other Education
168. Name
169. City & State
171. Completed?

     1. Not completed
     2. Graduated, degree earned
172. Number of years completed
173. Degree earned
175. Course of study
179. References

     List three (3) references (do not include relatives.)

181. Name
182. Phone number
183. Years known
184. Reference type

     1. Professional
     2. Personal
188. Name
189. Phone number
190. Years known
191. Reference type

     1. Professional
     2. Personal
195. Name
196. Phone number
197. Years known
198. Reference type

     1. Professional
     2. Personal
202. Certification and Authorization
     I hereby authorize Clay County Public Health Center to contact, obtain and verify the accuracy of information contained in this application from all previous employers, educational institutions, references, and to obtain reference information from previous employers and references regarding my work performance. My signature authorizes the Clay County Public Health Center to review my previous employment, driving, and criminal records, and/or other background data as it may relate to the position(s) for which I am applying or have been hired. I also hereby release form liability Clay County Public Health Center and its representatives for seeking, gathering and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that I will be required to take tobacco/nicotine, drug and alcohol tests if a job offer is made, but prior to employment. I acknowledge that if I test positive during one or more, or refuse to take, a tobacco/nicotine, drug or alcohol test, Clay County Public Health Center will rescind my job offer and I will no longer be considered for employment. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.
204. Applicants name
205. Date
207. Cover Letter
208. Resume
Leave This Blank:


210. 1. Receive an email copy of this form.
211. Email address

     This field is not part of the form submission.

212. Submit

* indicates a required field