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Jefferson County Health Center

On-line Employment Application

PO Box 580
2000 South Main Street
Fairfield, IA 52556
By submitting an application for employment I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of the application or immediate discharge from the employer's service, whenever it is discovered.

I give the employer the right to contact and obtain information for all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application; including conviction records, dependent adult abuse & child abuse records, and motor vehicle records (as needed for a specific position). I hereby release from liability the employer and its representatives for seeking, gathering, and using such information and all other persons, corporations or organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis by local, state or federal law.

This application is current for only 90 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

If I am hired, I understand that I are free to resign at any time, with or without cause and without proper notice, and the employer reserves the same right to terminate your employment at any time, with or without 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 representative of the employer, other than an authorized officer, has the authority to make any reassurances to the contrary. I further understand that any such assurance must be in writing and signed by an authorized officer.

I understand it is the company' policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA.

I understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions, by submitting this application.
  Position(s) applied for:
  Date
  Name (First, Middle, Last):
  Address(Street, City, State, Zip)
  Telephone number
  Cell phone number
  Employment type desired Full time
Part time
Occasional
Temporary
  If you are under 18, can you furnish a work permit? Yes
No
  Have you ever been employed here? Yes
No
  Are you legally eligible for employment in this country? Yes
No
  Are you able to meet the attendance requirements of the position? Yes
No
  Do you have a record of founded child abuse or dependent adult abuse or have you ever been convicted of a crime other than a simple misdemeanor offense related to motor vehicles and laws of the road under chapter 321 or equivalent provisions in this state or any other state? Yes
No
  If yes to the above question please explain:
  Have you ever been convicted, pled guilty to, or made a plea of no contest for any crime other than a traffic citation? Yes
No
  If you answered yes to the above question please explain:
  Emergency Notification(name, relationship & phone number)
  Employment History (1)
Dates From and To:
  Employer and Address
  Job Title:
  Telephone number
  Supervisor & Title:
  Summary of job responsibilities:
  Reason for leaving:
  Hourly Rate/Salary
Please provide starting and final wage.
  Employment History (2)
Dates From and To:
  Employer and Address
  Job Title:
  Telephone number
  Supervisor & Title:
  Summary of your responsibilities:
  Reason for leaving
  Hourly Rate/Salary
Please provide starting and final wage.
  Employment History (3)
Dates From and To:
  Employer and Address
  Job Title:
  Telephone:
  Supervisor & Title
  Summary of your job responsibilities:
  Reason for leaving:
  Hourly Rate/Salary
Please provide starting and final wage.
  Employment History (4)
Dates From and To:
  Employer and Address
  Job Title
  Telephone number
  Supervisor & Title
  Summary of your job responsibilities:
  Reason for leaving:
  Hourly Rate/Salary
Please provide starting and final wage.
  Skills/Qualifications
Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying:
  Educational Background (1)
High School attended and year graduated
  Educational Background (2)
College attended and year graduated and degrees earned:
  Educational Background (3)
Other education related to the field that you are applying for or would like to include in this employment application. Please include License numbers:
  Reference (1) (Must include at least one professional reference)
Please list name/relationship, telephone number and years known.
  Reference (2)
  Reference (3)