Careers - Macoupin County Public Health Department

* Position(s) Applying For

* Date Available

* Have you ever applied with us before?

Yes No

For What Position?

When?

* Have you ever been employed with us before?

Yes No

In What Position?

When?

	Years Completed	Did you graduate?
High School	1 2 3 4	Yes No
College/University	1 2 3 4	Yes No
Trade, Business, Correspondence School or Other	1 2 3 4	Yes No

* Please list special skills and/or qualifications you possess that directly relate to the position for which you are applying, such as knowledge of software, computer programs, and machinery and/or other office equipment you operate. * Please list workshops, courses, certification, or training you have completed that directly relate to the position for which you are applying.

* Why are you interested in us and/or this position?

Instructions: List your last four previous employers below, starting with your most recent employer. All information MUST be completed.

Not Applicable

Employer #1 - Current or Most Recent Employer

* Employment was:

Full-time Part-time Seasonal/Temp

* Employer Name

* Address, City, State, Zip

* Employer Telephone

* Supervisor Name

* May we contact this employer?

Yes No

* If no, please explain:

* Are you currently employed with this company?

Yes No

* From (mo/yr)* To (mo/yr)

* Duties performed and skills used or learned:

* Reason for leaving or looking for other employment

Employer #2

Employment was:

Full-time Part-time Seasonal/Temp

Employer Name

Address, City, State, Zip

Employer Telephone

Supervisor Name

May we contact this employer?

Yes No

If no, please explain:

Are you currently employed with this company?

Yes No

From (mo/yr)To (mo/yr)

Duties performed and skills used or learned:

Reason for leaving or looking for other employment

Employer #3

Employment was:

Full-time Part-time Seasonal/Temp

Employer Name

Address, City, State, Zip

Employer Telephone

Supervisor Name

May we contact this employer?

Yes No

If no, please explain:

Are you currently employed with this company?

Yes No

From (mo/yr)To (mo/yr)

Duties performed and skills used or learned:

Reason for leaving or looking for other employment

Employer #4

Employment was:

Full-time Part-time Seasonal/Temp

Employer Name

Address, City, State, Zip

Employer Telephone

Supervisor Name

May we contact this employer?

Yes No

If no, please explain:

Are you currently employed with this company?

Yes No

From (mo/yr)To (mo/yr)

Duties performed and skills used or learned:

Reason for leaving or looking for other employment

Instructions: List four work-related references you have known for at least one year. Do not list persons related to you.

Name/Occupation	Address, City, State	Telephone	Years Acquainted
*	*	*	*

Read the following information carefully before submitting below.

DISCLAIMER

I certify that all answers given are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

I agree to the Terms and Conditions

General Application

DISCLAIMER