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WCHD Employment Application

General Information * Last Name:
* Name:
Initial:
* Present Address: * City:
* State:
* Zip:
* Phone:
Position Applying For:

Will you require any reasonable accommodation(s) in order to permit you to perform the requirements?

Yes No

If so, please list:
When could you start employment?

Would you accept part-time employment?

Yes No

Have you ever been employed by the Winnebago County Health Department?

Yes No

If so, when and in what program(s):

Do you have relatives currently employed by the Winnebago County Health Department?

Yes No

If so, when and in what program(s):

Education History Highest Level of education attained:
If others, please list:

Advanced Education Reference 1:

Includes specialized training, technical schools, diploma nursing, undergraduates, graduates:

Name and address of institution or agency:
Name of Major:
Name of Minor:
Date Attended From:
Date Attended To:
Type of Degree Earned:

Advanced Education Reference 2:

Includes specialized training, technical schools, diploma nursing, undergraduates, graduates:

Name and address of institution or agency:
Name of Major:
Name of Minor:
Date Attended From:
Date Attended To:
Type of Degree Earned:

Advanced Education Reference 3:

Includes specialized training, technical schools, diploma nursing, undergraduates, graduates:

Name and address of institution or agency:
Name of Major:
Name of Minor:
Date Attended From:
Date Attended To:
Type of Degree Earned:

Registration(s), Certification(s), License(s) Reference 1: Registration, certification or other professional license:
Date Issued:
Date of Application:
Number:
State of Issue:

Registration(s), Certification(s), License(s) Reference 2: Registration, certification or other professional license:
Date Issued:
Date of Application:
Number:
State of Issue:

Registration(s), Certification(s), License(s) Reference 3: Registration, certification or other professional license:
Date Issued:
Date of Application:
Number:
State of Issue:

Employment History

List previous employers with most recent first. For each employer list an ddescribe your duties and responsibilities, if you had supervisory responsibilities, indicate thenumber of months involved and the number of job type of personnel supervised (e.g. clerical, technical, professional, administrative). Include military service.

Employer One Company One:
Address:
City:
State:
Zip:
Your Position:
Start Date:
End Date:
Starting Salary:
Ending Salary:
Immediate Supervisor: Phone Number: Reason for leaving. If still employed, why do you wish to leave?

Employer Two Company One:
Address:
City:
State:
Zip:
Your Position:
Start Date:
End Date:
Starting Salary:
Ending Salary:
Immediate Supervisor: Phone Number: Reason for leaving. If still employed, why do you wish to leave?

Employer Three Company One:
Address:
City:
State:
Zip:
Your Position:
Start Date:
End Date:
Starting Salary:
Ending Salary:
Immediate Supervisor: Phone Number: Reason for leaving. If still employed, why do you wish to leave?

Are there any employers you do not want us to contact?

Yes No If Yes, which:

List references who are not relatives:

Are you prevented from lawful employment because of your Visa or immigration status?

Yes No

Visa Type and other related information:

Authorization

I hereby certify that the following information contained in this application form is true and correct and I authorize personnel representatives of this facility to contact any of my schools, former employers or other references unless otherwise stated for the purpose of collecting information and an account of their experiences with me. I understand that if I am to be employed, any misrepresentation of the facts as stated on this application for is sufficient cause for dismissal. I also understand that I may be required to successfully complete a drug test and/or medical examination. This agreement does not bind either party for any specific period regarding employment.