Fillable EMPLOYMENT APPLICATION (Sarpy/Cass Health Department)

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EMPLOYMENT APPLICATION (Sarpy/Cass Health Department)

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  • 39 check-boxes
  • 143 other fields

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EMPLOYMENT APPLICATION
TYPE OR PRINT IN BLACK INK - These instructions must be followed exactly. Fill out application form completely. If questions
are not applicable, enter "N/A". Be sure to sign when completed. You may make copies of this application and enter different
position titles, but each copy must have an original signature. Resumes will not be accepted in lieu of applications. Sarpy/Cass
Health Department is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin,
gender, religion, age or disability in employment or the provision of services.
Mailing Address
City
State
Zip Code
Last Name First Name Middle
Cell Phone Number
Work Phone Number
Yes No
May we call you here?
Home Phone Number
List exact title or position for which you wish to apply: Minimum salary desired:
Yes No
Have you ever been convicted of a felony?
If your answer is "yes", explain in concise detail on a separate sheet of paper, giving the date and nature of the offense, the name
and location of the court, and the disposition of the case(s). A conviction may not disqualify you, but a false statement will. Note:
Some positions require additional information relating to misdemeanor convictions or deferred adjudication.
EDUCATION
Note: Applicants may be required to provide proof of diploma, degree, transcripts, licenses, certifications and registrations.
Type of School School Name and Location Dates Attended Graduated Diploma/Degree
Major/Minor Field of
Study
From To Yes No
High School
Undergraduate College
or University
Graduate School
Technical, Vocational
or Business School
Please list any other names used if different from name given on application:
If a license, certificate, or other authorization is required or related to the position for which you are applying, complete the
following:
LICENSE/CERTIFICATION
License Certification Date Issued
Issued by (State or
Authority)
License Number
Location of Issuing Authority
(City/State)
This information will be the official record of your employment history and must accurately reflect all significant duties performed.
Summary of experience should clearly describe your qualifications. A resume may be attached, but not substituted for the
requested information.
1. Include ALL employment. Begin with your current or last position and work back to your first.
2. Employment history should include each position held, even those with the same employer.
3. Give a brief summary of all the technical and, if appropriate, the managerial responsibilities of each position you have held.
EMPLOYMENT HISTORY
Address
City State Zip Code
Name of Employer
Phone Number Name of Supervisor
Reason for Leaving
From
Employed
To
Job Title & Responsibilities (use additional pages if necessary)
Temporary
Full-time
Part-time
Start
Pay Rate
Finish
Address
City State Zip Code
Name of Employer
Phone Number Name of Supervisor
Reason for Leaving
From
Employed
To
Job Title & Responsibilities (use additional pages if necessary)
Temporary
Full-time
Part-time
Start
Pay Rate
Finish
Address
City State Zip Code
Name of Employer
Phone Number Name of Supervisor
Reason for Leaving
From
Employed
To
Job Title & Responsibilities (use additional pages if necessary)
Temporary
Full-time
Part-time
Start
Pay Rate
Finish
Address
City State Zip Code
Name of Employer
Phone Number Name of Supervisor
Reason for Leaving
From
Employed
To
Job Title & Responsibilities (use additional pages if necessary)
Temporary
Full-time
Part-time
Start
Pay Rate
Finish
Address
City State Zip Code
Name of Employer
Phone Number Name of Supervisor
Reason for Leaving
From
Employed
To
Job Title & Responsibilities (use additional pages if necessary)
Temporary
Full-time
Part-time
Start
Pay Rate
Finish
Have you been given a copy of the job description?
A copy of a DD214 report from the Armed Services may be required.
MILITARY SERVICE
From
Dates of Service
To
SPECIAL SKILLS/QUALIFICATIONS
Yes No
Do you type?
List any equipment or machines with which you are proficient:
List any computer software with which you are proficient:
Do you speak a language in addition to English? Please list:
Yes No
Yes No
Are you able to perform the essential functions with or without reasonable accommodations?
Yes No
Do you use tobacco products?
WPM:
City
Please list three references:
Address City State Zip CodeName Phone Number
Name Address City State Zip Code Phone Number
Name Address State Zip Code Phone Number
REFERENCES
READ THE FOLLOWING STATEMENT CAREFULLY BEFORE SIGNING:
I AFFIRM THIS APPLICATION CONTAINS NO MISREPRESENTATION OR FALSIFICATIONS AND THAT THE INFORMATION
GIVEN BY ME IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I AM AWARE THAT SHOULD
INVESTIGATION AT ANY TIME DISCLOSE ANY SUCH MISREPRESENTATION OR FALSIFICATION, MY APPLICATION
WILL BE REJECTED OR, IF EMPLOYED BY THE HEALTH DEPARTMENT, I MAY BE TERMINATED FROM EMPLOYMENT. I
UNDERSTAND THAT I MUST PASS A CRIMINAL BACKGROUND INVESTIGATION, CREDIT CHECK AND PASS TESTING
FOR ALCOHOL AND SUBSTANCE USE/ABUSE, AS A CONDITION OF EMPLOYMENT. I ALSO UNDERSTANT THAT
DIRECT DEPOSIT OF PAY IS A CONDITION OF EMPLOYMENT. I UNDERSTANT THAT IF I AM EMPLOYED, I WILL SERVE
AN INTRODUCTORY PERIOD OF PROBATION OF AT LEAST SIX (6) MONTHS AND SUBJECT TO TERMINATION
WITHOUT RIGHT TO APPEAL. I FURTHER AUTHORIZE ANY AND ALL OF MY CURRENT OR PREVIOUS EMPLOYERS,
ASSOCIATES, OR REFERENCES TO PROVIDE THE PERSONNEL DEPARTMENT OR ANY DEPARTMENT ANY
INFORMATION CONCERNING MY EMPLOYMENT RECORD OR CHARACTER. FINALLY, I AUTHORIZE THAT COPIES OF
THIS APPLICATION MAY BE FURNISHED TO INTERESTED SARPY/CASS HEALTH DEPARTMENT'S OFFICES/
DEPARTMENTS.
Date
Mail or bring your completed application to the Sarpy/Cass Health Department at the address listed above. The Personnel
Department cannot be responsible for applications sent directly to departments, other individuals, or other public or private
agencies.
Interviews are not conducted at the time of application. When applying for a position that is currently available, your application
will be reviewed and you will be contacted either by telephone or mail regarding the status of your application.
Applications are retained for a period of one calendar year from date of receipt. If you are not contacted within 90 days for
possible employment and are still interested in employment with the Sarpy/Cass Health Department, we require that you call our
office to update your application in order to be considered for future openings.
Employees of the Sarpy/Cass Health Department are at will and may resign their employment or be terminated at any time as
provided in the Sarpy/Cass Health Department Policies and Procedures Manual.
Sarpy/Cass Health Department is an equal opportunity employer and will not discriminate against any employee or applicant.
Accommodations are available for applicants with disabilities in all phases of the application and employment process. Contact
the Personnel Department for an auxiliary aid or service.
Sarpy/Cass Health Department maintains a drug free workplace and will not tolerate the use, possession or distribution of illegal
substances. Employees must abide by the Health Department's drug and alcohol use/abuse screening procedures.
THANK YOU for considering employment with the Sarpy/Cass Health Department. Depending on the number of applications and
any examination requirements, we strive to complete the entire hiring process within one month of the position closing.
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EMPLOYMENT APPLICATION (SarpyCass Health Department)

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Completed 13 February 2021

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