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  1. Clay County Public Health Center Job Application

    Clay County Public Health Center requires a pre-employment Drug, Alcohol & Tobacco/Nicotine Screening We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application in used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and /or interview process should notify a representative of the Health Center.

  2. Hours of employment desired

  3. Are you able to meet the attendance requirements of the job you are applying for?

  4. Can you perform the duties of the job you are applying for?

  5. Do you have any objection to working overtime, if necessary?

  6. Can you travel if required by this position?

  7. Have you ever been previously employed by our organization?

  8. Do you have relatives, guardians and/or wards presently employed at Clay County Public Health Center?

  9. If necessary for the job, can you provide a valid driver's license and/or proof of auto insurance?

  10. Can you submit proof of legal employment authorization and identity?

  11. Are you authorized to work lawfully in the United States?

  12. Will you now or in the future require our company to commence immigration sponsorship to employ you?

  13. If you are under 18, can you furnish a work permit if it is required?

  14. Have you used tobacco/nicotine containing products or controlled substances "drugs" in the last six (6) months?

    (A criminal record or conviction will not automatically bar employment, but will be considered as it relates to the position for which you are applying).

  15. Have you pled "guilty" or "no contest" to, or been convicted of a crime within the last seven (7) years?

  16. Employment History

    Please provide all employment information for your past four (4) employers, starting with the most recent.

  17. May we contact your present employer?

  18. High School

  19. Completed?

  20. College

  21. Completed?

  22. Graduate degree

  23. Completed?

  24. Technical Training

  25. Completed?

  26. Other Education

  27. Completed?

  28. References

    List three (3) references: include names, telephone numbers and number of years known, do not include relatives.

  29. Certification and Authorization

    I hereby authorize Clay County Public Health Center to contact, obtain and verify the accuracy of information contained in this application from all previous employers, educational institutions, references, and to obtain reference information from previous employers and references regarding my work performance. My signature authorizes the Clay County Public Health Center to review my previous employment, driving, and criminal records, and/or other background data as it may relate to the position(s) for which I am applying or have been hired. I also hereby release form liability Clay County Public Health Center and its representatives for seeking, gathering and using such information to make employment decisions and all other persons or organizations for providing such information. I understand that I will be required to take tobacco/nicotine, drug and alcohol tests if a job offer is made, but prior to employment. I acknowledge that if I test positive during one or more, or refuse to take, a tobacco/nicotine, drug or alcohol test, Clay County Public Health Center will rescind my job offer and I will no longer be considered for employment. I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law. I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA. I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment. I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

  30. Leave This Blank:

  31. This field is not part of the form submission.