Employment Application – Bent County Public Health

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BENT COUNTY PUBLIC HEALTH

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Services
Employment
- Open Positions
- Employment Application
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BENT COUNTY PUBLIC HEALTH

Home
Services
Employment
- Open Positions
- Employment Application
About
Contact Us
Search for:

Application for Employment

Today's Date*
Date Format: MM slash DD slash YYYY
Personal
First Name*
Last Name*
Email*
Social Security Number*
Driver's License No.*
State Issued From*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Availability
Position Applying For:*
Expected Pay*
Per(select one)*
- Hour
- Month
- Year
Are you able to work*
- Select All
- Full Time
- Part Time
- Weekends
- Other
If you choose "Other" please fill out the comment section at the bottom with your availability.
Date able to start*
Date Format: MM slash DD slash YYYY
Relatives currently working for us?
First Name Last Name

If this does not apply then skip this.
Have you worked for us before?*
- Yes
- No
If yes, provide dates*
Date Format: MM slash DD slash YYYY
Postion?*
Education
Do you have any specialized experience, skills, or qualifications pertaining to the job you are applying for?
High School*
Name City/State Degree Graduate? (Yes or No)
College
Name City/State Degree Graduate? (Yes or No)
Other
Name City/State Degree Graduate? (Yes or No)
Security
List states and counties of residence for the past seven years*
Have you used names or social security numbers other than what is given above?*
- Yes
- No
If Yes, Describe Below*
Have you been convicted of a felony and / or served time in the past 7 years?*
- Yes
- No
If Yes, Describe Below*
References: List only individuals familiar with your work ability. Do not include relatives.
Name Title Relationship Phone Number Email Address
Employment History: Most Recent Employer
Company Name
Telephone
City
State
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
- Current
Job Title
Supervisor's Name
Salary
Do not include $ sign.
Per
Duties:
Reason for Leaving:
Second Most Recent Employer
Company Name
Telephone
City
State
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
- Current
Job Title
Supervisor's Name
Salary
Do not include $ sign.
Per
Duties:
Reason for Leaving:
Third Most Recent Employer
Company Name
Telephone
City
State
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
- Current
Job Title
Supervisor's Name
Salary
Do not include $ sign.
Per
Duties:
Reason for Leaving:
Fourth Most Recent Employer
Company Name
Telephone
City
State
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
- Current
Job Title
Supervisor's Name
Salary
Do not include $ sign.
Per
Duties:
Reason for Leaving:
Comments or anything else you want us to know in relation to this application.
Upload a Resume and Cover letter*
Drop files here or
Consent*
I certify that answers given are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application as necessary in arriving at an emplyment decision. If any statements are found to be falsified or misrepresented, my application may be rejected or I mey be relieved of my job duties at any time. This application shhall be considered active for a period not to exceed one year.
Consent*
I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment as in accordance with the company's policies.

First Name	Last Name

Name	City/State	Degree	Graduate? (Yes or No)

Name	City/State	Degree	Graduate? (Yes or No)

Name	City/State	Degree	Graduate? (Yes or No)

BENT COUNTY PUBLIC HEALTH

Application for Employment

Personal

Availability

Education

Security

References: List only individuals familiar with your work ability. Do not include relatives.

Employment History: Most Recent Employer

Second Most Recent Employer

Third Most Recent Employer

Fourth Most Recent Employer