HOLMES COUNTY HEALTH DEPARTMENT
Application for Employment
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SECTION 1: Personal Information
Last Name: First Name: Middle Initial:
Home Address:
City/State/Zip: Social Security Number
Home Phone: Work Phone:
Convenient time to call:
The following information will be used only if directly related to the position for which you are applying. Type Yes or No next to the question.
1. Do you have an Ohio Driver’s License?
2. If the position requires, can you provide your own transportation?
3. Have you ever been convicted of a felony?
4. Have you ever been employed in State or County service in Ohio?
If you are currently a State or County employee please state current job title:
SECTION 2: Education
List names of schools, number of years, degrees earned.
High School:
College:
Other:
Do you possess a professional license or certificate? ___ If so, give the name and location of the licensing board and registration or certificate number of license issued.
Have you had special training in public health? ___ If so, give details:
SECTION 3: Position and Qualifications
What position are you applying for in this department?
State your qualifications for this position:
Date available to begin work:
If applying for a clerical position, what office machines do you operate?
Please list type of computer and computer software you are capable of using:
SECTION 5: References
Please list name, address, and phone number for two persons other than relatives who have knowledge of your character, experience, and ability.
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2.
SECTION 4: Employment History
Please list your previous employment, beginning with your last or present position, salary, dates of employment, position and reason for leaving. Include salary history and current salary requirement. Attach additional page if necessary.
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