Public Health Employment Application

Contact Information

1. First Name
2. Middle Name
3. Last Name
4. Address
5. City
6. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7. Zip
8. Phone
9. Email
10. Position you are applying for: Choose an open position. Are you looking to apply for a job in a different department? Please use our standard employment application.
11. Date Available
12. Are you 18 or Older? Please Select Yes No
13. Do you have a legal right to work in the United States full-time? Please Select Yes No
14. Have you ever been employed by Marion County? Please Select Yes No
Employed Start Date:
Employed End Date:
Employed Position
Reason for Leaving

Education

High School

15. Name and Location
16. Did you Graduate? Please Select Yes No No, but received GED

College or Trade School

17. Name and Location
18. Did you Graduate? Please Select Yes No
19. Major/Subject

Employment History

List employment from the past 10 years, starting with your most recent job. Account for any time period that you were unemployed by stating the nature of your activities.

Employer 1

20. Employer Name
21. Job Title
22. Address
23. City
24. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
25. Zip
26. Phone
27. Start Date
28. End Date
29. Current/Ending Pay
30. Supervisor Name
31. Work Performed
32. Reason For Leaving
33. Can we contact current employer? Please Select Yes No
Add Employer

Employer 2

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor Name

Work Performed

Reason For Leaving Add Employer

Employer 3

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor

Work Performed

Reason For Leaving

Additional Employers

Optional: Upload Resume

34. Resume
    only PDF files are allowed

Additional Information

35. List any professional, trade groups, organizations, machinery/tools operated in the past, and/or special skills that you consider relevant to your ability to perform this job.
36. Were you in the Military? Please Select Yes No
Branch
Do you have any experience from your military service that would be relevant to the job(s) for which you are applying? If yes, please explain:

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37. Have you ever been convicted of a felony?
    For purposes of these questions, convicted includes plead guilty, plead no contest, or been given a deferred sentence of judgment. Please Select Yes No
If yes, please explain.
Note: A conviction will not automatically disqualify an applicant for a particular job and that the type and seriousness of the crime, the frequency of violoations, the date of conviction, and the applicant's entire work and educational history will be considered.

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Job Description

38. Have you read the job description? Please Select Yes No
39. Do you understand the requirements? Please Select Yes No
40. Can you perform the requirement of this job with or without reasonable accommodations? Please Select Yes No

Driver's License

41. If the job requires, do you have the appropriate valid driver's license? N/A Yes No
Driver's License #
License Type
State of License Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Have you had any moving violations? Please Describe:

Confidential Information

As required, we comply with government regulations including Affirmative Action obligations where they apply.

In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations, we ask that you complete this applicant survey. Your cooperation is appreciated.

Please be advised that your survey is not part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.

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42. Please select one. American Indian or Alaskan Native: persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.
    White, not of Hispanic Origin: persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
    Black, not of Hispanic Origin: persons having origins in any of the Black racial groups of Africa.
    Asian, or Pacific Islander: persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.
    Hispanic: persons of Mexican, Puerto Rican, Cuban, Central of South American, or other Spanish culture or origin, regardless of race.
    Other

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43. Gender Please Select Male Female
44. Age Please Select Under 20 20-24 25-34 35-49 50-64 65 and Over

Notices

I understand:

That completing this application does not constitute an offer of employment.

That in connection with the application process, Marion County may conduct a background investigation and request information from my past employers, education institutions, personal references, and any public or private agencies that have issued me either a professional or vocational certification or license. I understand that such investigation may also include, but is not limited to, any criminal records and motor vehicle driving records. I have read Marion County's Applicant Background Checks and Employee Investigation Policy, which I fully understand and which indicates that if Marion County utilizes the services of a consumer reporting agency, the Company follows the provisions of the Fair Credit Reporting Act and will provide a notice to the applicant and request a separate Release of Information form from the applicant.

That I may be required to complete a medical history form and may be required to be examined by a medical professional designated by Marion County at the post-offer stage. I agree that Marion County shall be entitled to receive full and complete reports and records governing any medical or related examinations, and I authorize any and all such doctors, medical examiners, and clinics/hospitals to give to Marion County full and complete reports and records covering such examinations.

That use of illegal drugs is prohibited during employment and that I may be required to undergo and successfully pass a screening for alcohol and/or drugs that is included in a post-offer pre-employment physical examination. I also understand that, if employed, I may be required to submit to an alcohol or drug screening according to state law. I agree that Marion County shall be entitled to receive full and complete reports and records governing any alcohol or drug screening, and I authorize any and all such doctors, medical examiners, and clinics/hospitals to give to this organization full and complete reports and records covering such examinations.

That if I sustain any injury or illness while in the employment of this organization, I agree that Marion County shall be entitled to receive full and complete reports and records governing any medical or related examinations, and I authorize any and all such doctors, medical examiners, and clinics/hospitals to give to Marion County full and complete reports and records covering such examinations, condition, care and treatment related to or resulting from the alleged illness or injury.

That if employment is obtained under this application, I will comply with all rules and policies of the organization. I agree to be responsible for the organization’s property and equipment issued to me by the organization until returned by me. I agree to pay for property and equipment not returned, and authorize the organization to withhold an amount equal to the value of the property not returned by me from my final pay.

That this employment application and any other employee related documents are not contracts of employment and that Marion County follows an “employment at-will” policy that an individual who is hired may voluntarily leave employment or may be terminated by the employer at any time for any or no reason. I understand that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by any prospective or existing employee.

Smoking Ban Notice:

Applicants for employment with Marion County are advised that smoking is banned by state law (Iowa Code Chapter 142D) on all Company grounds and in all Company facilities which includes motor vehicles and equipment. Applicants are further advised that their job duties may include entering into areas where smoking is not regulated and where smoking is occurring. (Iowa Code Section 142d.6(2))

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I have provided complete and truthful information to Marion County regarding all sources of information about my past employment, education, licensure, certification, criminal conviction record, as well as any other information requested in the employment application, and have been fully informed that any misrepresentations or material omissions concerning such information will be grounds for denying my application, withdrawing any offer of employment, or immediate discharge.

I have carefully read all the statements regarding requests, authorizations, consents and releases and have voluntarily agreed to assist Marion County in evaluating my qualifications for employment and in meeting the business necessity of hiring honest, trustworthy, reliable and non-violent employees who do not pose a risk of serious harm in the workplace.

I understand that with the exception of any credit or investigative reports received under the Fair Credit Reporting Act, all information and documents generated, received or maintained by Marion County during, or as a result of, its investigation will be maintained as confidential information in Human Resources and Marion County will not release such information or documents to me.

Your Signature

45. Signature Please type your full name to serve as an electronic signature.
46. Today's Date