Will you require any reasonable accommodation(s) in order to permit you to perform the requirements?
Would you accept part-time employment?
Have you ever been employed by the Winnebago County Health Department?
Do you have relatives currently employed by the Winnebago County Health Department?
Includes specialized training, technical schools, diploma nursing, undergraduates, graduates:
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.
Are there any employers you do not want us to contact?
Are you prevented from lawful employment because of your Visa or immigration status?
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.
401 Division Street P.O. Box 4009,
Rockford, IL 61110-0509 • Phone: 815-720-4000 • Fax: 815-720-4001