Employment Application - Taney County Health Department

Application for Employment

We are pleased that you are interested in applying for a position with our Health Department. Taney County Health Department is an equal opportunity employer and does not discriminate in hiring or employment practices on the basis of race, color, religious creed, national origin, age, sex, marital status, ancestry, veteran status, pregnancy, medical condition, citizenship status, genetic information, sexual orientation, gender identity, disability or other basis prohibited by applicable local, state, or federal law. No question on this form is intended to secure information to be used for such discrimination.

Personal Information

Name*

First Last

Email*

Position(s) applying for*

Position(s) Desired or Area of Interest:*

Full Time
Part Time
PRN
Temporary

Preferred Name

Telephone

Daytime Number

Address*

Street Address Address Line 2 City State ZIP Code

Have you ever worked under a different name?*

Yes
No

Other name(s) under which you have been previously employed

Have you ever been employed by us?*

Yes
No

If Yes, when?

Do you have any relatives working here?*

Yes
No

If yes, indicate name and relationship

Are you 18 years of age or older?*

Yes
No

Have you ever been bonded?*

Yes
No

Are you legally eligible for employment in the United States?*

Yes
No

Note: Proof of eligibility will be required within three working days of employment.

Are you capable of performing the essential functions required for the position for which you are applying with or without an accommodation?*

Yes
No

Have you ever pled guilty, “no contest” to, or been convicted of a felony?*

Yes
No

If yes, please give the date(s) and details:

Note: Answering “Yes” to the question above does not constitute an automatic bar from employment. Factors such as age, time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.

Education

Where did you attend High School, College/University, Post Graduate, Business/Trade Technical ?*

Name and Location of School	Course of Study	Last Grade Completed	Did you Graduate?	Degree/Diploma

(Click the + button to add a new row)

Special Skills, Training or Qualifications:

Describe any computer skills, specialized skills, training and qualifications you possess and/or internships you feel are relevant to the position for which you are applying

Employment History

Beginning with your most recent position, enter your employment information here

May we contact this employer?

Yes
No

Company Name (Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

Did you have another job before this one?*

Yes
No

May we contact this employer?

Yes
No

Company Name (Second Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

Would you like to list another previous job?

Yes
No

May we contact this employer?

Yes
No

Company Name (Third Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

Would you like to list a 4th job?

Yes
No

May we contact this employer?

Yes
No

Company Name (Fourth Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

References

List 3-5 people we may contact who are qualified to evaluate your capabilities. Do not include relatives. (Click the + button to add a new row)

Name	Address	Occupation	Years Known

Availability

Hours Available

Please list your availability for work, including the day(s) of the week and specific time(s) of the day

How many hours per week would you like to work?

On what date would you be available for work?

Rate of pay expected $

(per hour or annualized salary)

How did you hear about a position with us?

Location Preference(s)

Branson
Forsyth
Hollister

Applicant’s Statement:

Please read statements below carefully before signing this employment application disclosure.

I certify that the answers provided on this application are true, accurate and complete. I understand that any false information, omissions, or misleading information contained in this application or during the interview process, may be grounds for refusal to hire or may result in immediate termination. I acknowledge the confidential nature of the Health Department’s business and agree to maintain the confidentiality of the business affairs of the Health Department and its customers, at all times, before, during and after my employment.

I acknowledge that an offer and acceptance of employment is of an "at will" nature, which means that I may resign at any time and the employer may discharge me at any time with or without cause. I further understand that no supervisor, manager or representative of Taney County Health Department has any authority to enter into an agreement for employment for any specific period of time or to make any agreement contrary to these terms of employment, except such person or persons to whom such authority has been specifically granted by Taney County Health Department Board of Trustees.

I voluntarily consent to submit to a drug test at the request and expense of the Health Department and understand that Taney County Health Department reserves the right to conduct random drug testing. For employment purposes and with my prior written consent, the Health Department may investigate my driving record from time to time during my employment. I understand, if hired, I will be required to provide proof of identity and legal authorization to work in the United States. I also understand that Taney County Health Department participates in the United States Department of Homeland Security E-Verify program. I understand that, if hired, a criminal background check will be conducted and my employment is contingent upon the results of that check as it pertains to my job duties.

I understand that my application for employment shall remain in Taney County Health Department’s active files for a period of six months. Active files will be purged of applications and/or resumes on file for more than six months. If I wish to extend my candidacy, I must reapply by submitting another employment application.

I hereby authorize all previous employers, to release to Taney County Health Department any and all information regarding my employment. In addition, I authorize Taney County Health Department to contact and obtain information from all references, employers, public agencies, licensing authorities and educational institutions to verify the accuracy of all information. I hereby further release Taney County Health Department, and any and all of its employees, of liability relating to, lawfully seeking and using truthful and nondefamatory information in the employment process.

I have carefully read, understand and will comply with all aspects of the employment disclosures stated in this document, and understand that completion of this application is not to be considered an offer of employment.

Digital Signature:*

Printing your First Name + Middle Initial + Last Name will act as your digital signature.

Date