Employment Application

function winwar_disable_akismet() {
return false;
}
add_filter(“gform_akismet_enabled_4”, “winwar_disable_akismet”);

Step 1 of 9

Equal access to programs, services and employment opportunities is available to all persons without regard to age, ancestry, citizenship status, color, physical or mental disability, genetic information, marital status, military status, national origin, race, religion, sex (including pregnancy), sexual orientation, or any other basis protected by federal, state, and/or local law.

In accordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department. Examples of reasonable accommodations include making a change to the application process; providing written materials in an alternate format such as braille, large print, or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions.
Name*
First Middle Last
Applicant ID #
Address*
Street Address City State ZIP Code
Telephone #*
Other phone #
Email*
Position(s) applied for:*
Referral source (e.g. Company Site, Job Posting, etc.)*

Employment History
Starting with your most recent employer, provide the following information. You may include any verified work performed on a volunteer basis.
Employer #1
Employer
Phone #
Address
Street Address City State
Starting job title
Dates employed
Immediate supervisor and title (for most recent position held)
Email
May we contact for reference?
- Yes
- No
- Later
Summarize the type of work performed and job responsibilities:
Why did you leave?
What did you like most about your position?
What did you least like about your position?
Employer #2
Employer
Phone #
Address
Street Address City State
Starting job title
Dates employed
Immediate supervisor and title (for most recent position held)
Email
May we contact for reference?
- Yes
- No
- Later
Summarize the type of work performed and job responsibilities:
Why did you leave?
What did you like most about your position?
What did you least like about your position?

Employment History (continued)
If you do not have more experience to fill out, continue to the next page.
Employer #3
Employer
Phone #
Address
Street Address City State
Starting job title
Dates employed
Immediate supervisor and title (for most recent position held)
Email
May we contact for reference?
- Yes
- No
- Later
Summarize the type of work performed and job responsibilities:
Why did you leave?
What did you like most about your position?
What did you least like about your position?
Employer #4
Employer
Phone #
Address
Street Address City State
Starting job title
Dates employed
Immediate supervisor and title (for most recent position held)
Email
May we contact for reference?
- Yes
- No
- Later
Summarize the type of work performed and job responsibilities:
Why did you leave?
What did you like most about your position?
What did you least like about your position?

Applicant Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete, and correct.

I expressly authorize, without reservation, the employer, its representatives, employees, or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law.

I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that reasonable safeguards will be taken to protect all personal information provided or obtained in conjunction with this application for employment. My personal information may be shared with the employer's affiliate(s) and third parties engaged by the employer to perform services for the employer. Any personal information shared with an affiliate or third party is to be used solely to perform the services requested by the employer.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her age, ancestry, citizenship status, color, physical or mental disability, genetic information, marital status, military status, national origin, race, religion, sex (including pregnancy), sexual orientation, or any other protected status wider applicable federal, state, or local law.

Please be advised pursuant to Illinois law, applicants are not obligated to disclose expunged juvenile, records of adjudication, arrest, or conviction.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement.
Name of Applicant*
Date*
MM slash DD slash YYYY

	N/A	Basic	Intermediate	Advanced
Word Processing
Presentation
Email
Internet
Spreadsheet

Employment Application

Step 1 of 9

Employment History

Employment History (continued)

Employment History (continued)

Skills and Qualifications

Educational Background

References

Related Information

Applicant Statement

Contact Us

Egyptian Health Department
Main Office

Recovery
Resource Center

Egyptian Health Department
Shawneetown Office

Gallatin County
Wellness Center

Egyptian Health Department
Carmi Office

Egyptian Behavioral Health
Fairfield Office

Egyptian Health Department
Downtown Office

The Support Deck

Employment Application

Step 1 of 9

Employment History

Employment History (continued)

Employment History (continued)

Skills and Qualifications

Educational Background

References

Related Information

Applicant Statement

Contact Us

Egyptian Health Department Main Office

Recovery Resource Center

Egyptian Health Department Shawneetown Office

Gallatin County Wellness Center

Egyptian Health Department Carmi Office

Egyptian Behavioral Health Fairfield Office

Egyptian Health Department Downtown Office

The Support Deck

Egyptian Health Department
Main Office

Recovery
Resource Center

Egyptian Health Department
Shawneetown Office

Gallatin County
Wellness Center

Egyptian Health Department
Carmi Office

Egyptian Behavioral Health
Fairfield Office

Egyptian Health Department
Downtown Office