Greene County Health Department Employment Application

Name

Email Address

Phone Number

Present Address (Street Address, City, State, Zip Code)

Referred by (If applicable)

What position are you applying for?

When can you start? (date)

Desired salary:

Are you currently employed? Are you currently employed? Yes No

May we inquire of your present employer? May we inquire of your present employer? Yes No

Have you ever applied with the Greene County Health Department? Have you ever applied with the Greene County Health Department? Yes No N/A

When you applied in the past, what did you apply for and when? (Leave blank if not applicable)

High School (Name & Location, years attended, did you graduate, and subjects studied)

College (Name & Location, years attended, did you graduate, and subjects studied)

Trade, Business, or Other School (Name & Location, years attended, did you graduate, and subjects studied)

Former Employer (Enter the name, address, dates worked, and job title)

Former Employer (Enter the name, address, dates worked, and job title)

Former Employer (Enter the name, address, dates worked, and job title)

Former Employer (Enter the name, address, dates worked, and job title)

Reference 1 (Enter name - email - affiliation - years known)

Reference 2 (Enter name - email - affiliation - years known)

Reference 3 (Enter name - email - affiliation - years known)

Enter todays date:

Entering your name in this box acts as your signature that you agree to the following statement: "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all in­ formation concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. I understand that a consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, Iunderstandthat,incompliancewithfederallaw,thecompanywillprovidemewithawrittennoticeregardingtheuseofthese reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment." In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to com­ plete the required employment eligibility verification document form upon hire.