APPLICATION FOR EMPLOYMENT
Date of Application:
Position Applied For:
Last Name:
First Name:
Street Address:
City:
State:
Zip Code:
Email Address:
Telephone Number:
How did you learn about us?
Salary Expected:
On what date would you be available for work?
Type of Employment Desired: Full Time Part Time Other
Have you filled an application here before? Yes No
If yes, Date:
Have you ever been employed here before? Yes No
Are you 18 years of age or older? Yes No
Will you work overtime, if required? Yes No
Will you travel if job requires it? Yes No
Have you been convicted of a felony within the last 7 years?
Yes No (conviction will not necessarily disqualify an applicant from employment)
If Yes, explain:
Are you legally eligible for employment in this country?
Yes No (Proof of U.S. citizenship or immigration status will be required upon employment)
EDUCATION - List all schools attended
High/Prep Schools:
Name and address of school:
No of years completed:
Did you graduate?
Degree:
High School Courses:
College / University
College Major:
Other Education
Courses:
PROFESSIONAL LICENSES, CERTIFICATIONS, SKILLS AND QUALIFICATIONS
List any state in which you are or have been licensed or certified:
Have you ever had any professional license or certification placed under investigation, disciplined, suspended, revoked or put on probation? Yes No
Indicate any special skills or any information you think would be helpful in considering you for employment with the Tuscola County Health Department, i.e., additional education, experience, activities, accomplishments:
EMPLOYMENT HISTORY
Company Name:
Supervisor:
Address:
Phone:
Employment Dates:
Job Title/Description of Work:
Beginning Salary:
Ending Salary:
Reason for Leaving:
Comments: (including explanation of any gaps in employment)
May we contact the employers listed above? Yes No
If no, indicate those you do not wish us to contact:
REFERENCES - business and professional only
Name:
Title:
Company:
U.S. MILITARY STATUS AND RECORD
Branch of Service:
Dates of Service From: To:
Describe any specialized training and duties:
Were you honorably discharged?
Do you have a reserve or National Guard obligation? Yes No
If Yes, please describe:
Please attach resume here.
PRE-EMPLOYMENT STATEMENT
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at any employment decision. I understand that any false answers or statements or misleading omissions made by me on this application or any document submitted along with this application in connection with the above mentioned investigation, can be sufficient grounds for my rejection as a candidate for employment or immediate discharge. I hereby authorize all my current or previous employers, education institutions, and other references listed above to furnish to the Tuscola County Health Department any information they may have on record or otherwise concerning me, excluding information related to medical conditions or disability. I agree and understand that any employment offer is conditional until such time as the results of my reference checks, physical examination and drug screening are completed. I must satisfactorily pass these to obtain employment. Under Michigan law, the Tuscola County Health Department complies with the Americans with Disabilities Act and applicable state and local laws providing for nondiscrimination in employment against qualified individuals with disabilities. The Health Department also provides reasonable accommodation for such individuals in accordance with these laws. This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature, which means the employee may resign at any time and the employer may discharge the employee at any time, with or without cause. It is further understood that this at will employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. Having made application for employment, I hereby authorize the Tuscola County Health Department, through the Michigan State Police Criminal Justice Information Center to do a background check of my past record to ascertain any and all information which may concern my police record, character, whether such information is of record or not. I hereby release my present and past employers, reference, any criminal justice agency and all persons, whoever, from any liability because of furnishing said information.
Driver's License Number:
Signature of Applicant:
Date:
As an Equal Opportunity Employer, we base employment decisions on job-related information. All legal requirements pertinent to fair employment practices are complied with by the Tuscola County Health Department.