Application for Employment

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Position(s) Applied For:(Required)

Date of Application:(Required)

Name:(Required)

First Middle Last

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

If you are under 18 years of age, can you provide required proof of your eligibility to work?(Required)

Yes

Not Applicable

Have you ever filed an application with us before?(Required)

Yes

Have you ever been employed with us before?(Required)

Yes

Are you currently employed?(Required)

Yes

May we contact your present employer?

Yes

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?(Required)

Yes

Proof of citizenship or immigration status will be required upon employment.

On what date would you be available to work?(Required)

Are you available to work:(Required)

Full Time

Part Time

Shift Work

Temporary

Are you currently on “lay-off” status and subject to recall?(Required)

Yes

Can you travel if a job requires it?(Required)

Yes

Education

High School Name:

High School Address:

Street Address Address Line 2 City State ZIP Code

Years of High School Completed:

High School Degree/Diploma Received:

Undergraduate College Name:

Undergraduate College Address:

Street Address Address Line 2 City State ZIP Code

Undergraduate College Course of Study:

Years of Undergraduate College Completed:

Undergraduate College Diploma / Degree Received:

Graduate Professional School Name:

Graduate Professional School Address:

Street Address Address Line 2 City State ZIP Code

Graduate Professional School Course of Study:

Years of Graduate Professional School Completed:

Graduate Professional School Diploma / Degree Received:

Other Education (Specify):

Describe any job-related specialized training, apprenticeship, skills, or qualifications from other employment, military or other experiences:

Specialized Skills:

Word Perfect

Desktop Publishing

Internet

Excel

Calculator

MS Word

Check all that apply.

Please list any specialized skills with Production / Mobile Machinery:

Please list any additional specialized skills not already listed here:

References

Name:

First Last

Address:

Street Address Address Line 2 City State ZIP Code

Phone:

Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:

Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer:

Employment Start Date

Employment End Date

Employer Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone Number:

Job Title:

Supervisor Name:

Reason for leaving:

Starting Hourly Rate / Salary

Final Hourly Rate / Salary

Work Performed:

Employer:

Employment Start Date

Employment End Date

Employer Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone Number:

Job Title:

Supervisor Name:

Reason for leaving:

Starting Hourly Rate / Salary

Final Hourly Rate / Salary

Work Performed:

Employer:

Employment Start Date

Employment End Date

Employer Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone Number:

Job Title:

Supervisor Name:

Reason for leaving:

Starting Hourly Rate / Salary

Final Hourly Rate / Salary

Work Performed:

Employer:

Employment Start Date

Employment End Date

Employer Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone Number:

Job Title:

Supervisor Name:

Reason for leaving:

Starting Hourly Rate / Salary

Final Hourly Rate / Salary

Work Performed:

Criminal History

A Criminal Background Check may be required for hiring.
A Drug and/or Alcohol test may be required before hiring.

Have you been convicted of a felony or any crime which carried the potential of a jail sentence in Wyoming or any other state or territory of the United States or any foreign country?(Required)

Yes

(This does not include minor traffic offenses, but does include alcohol related traffic incidents or convictions resulting from accidents involving injury to persons)

If yes, please explain and provide the date of conviction(s), the nature and title of the offense and the jurisdiction in which the conviction occurred:

Applicant’s Statement

I certify that answers given herein 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.

This application for employment is effective for the position approved for only. A separate application must be submitted for each position vacancy.

I hereby understand and acknowledge that Cheyenne Laramie County Public Health is an at-will employer. Either Cheyenne Laramie County Public Health or the employee can terminate employment at any time for any reason, or no reason. There are no promises, express or implied, for continued employment, and no one nor any individual Board member may waive or modify these conditions of employment. Cheyenne Laramie County Public Health policies are not intended to be construed as part of any employment relationship and/or contract, and are simply general statements or organizational policy. Cheyenne Laramie County Public Health policies are subject to change under direction of the governing body, the Board of Health..

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand that I am required to abide by all rules and regulations of the employer.

Signature

Draw your signature.

Date