PUBLIC HEALTH - DAYTON & MONTGOMERY COUNTY APPLICATION PROCEDURES

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1 PUBLIC HEALTH - DAYTON & MONTGOMERY COUNTY APPLICATION PROCEDURES 1. A completed Application for Employment and Consent to Procurement of Consumer Credit Report are mandatory. The Office of Human Resources accepts those documents for employment, which may be accompanied by a resume, Monday through Friday between the hours of 8:00 a.m. and 4:30 p.m. 2. Application materials mentioned above can either be faxed to (937) or ed to 3. Application materials are kept on file for six months from the date it is received in Human Resources. 4. Interviews are not given at the time application materials are submitted. Only qualified candidates will be contacted by the appropriate supervisor to schedule an interview. If you are not selected for a position your application materials will remain on file for six months. If the position you applied for is posted again within six months, your application materials will be forwarded to the appropriate division for consideration at that time. 5. The Public Health Dayton & Montgomery County website, phdmc.org, and the job line, , are available for your convenience. THANK YOU FOR YOUR INTEREST IN EMPLOYMENT WITH PUBLIC HEALTH We are an equal opportunity Employer/Service provider

2 PUBLIC HEALTH - DAYTON & MONTGOMERY COUNTY Office of Human Resources Applicant EEO Data Sheet Responses to the following questions are OPTIONAL. These questions are included to assist our equal employment opportunity efforts. Providing this information is VOLUNTARY and will in no way affect the processing of your application or your being considered for employment. This information will be kept separately from your application. Responses will be used for statistical purposes only. Do not place your name on this form. Position applied for Date 1. Optional: Sex: Female Male 2. Optional: Please select your age group: Under Optional: Race/Ethnicity Asian: All persons having origins in any of the original people of the Far East, Southeast Asia, the Indian Subcontinent (for example, China, India, Japan, Korea). American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition. Black or African American: All persons having origins in any of the Black racial groups of Africa. Hispanic or Latino: All persons of Mexican, Puerto Rican, Cuban, Central or South America or other Spanish culture or origin, regardless of race. Native Hawaiian or Pacific Islander: All persons having origins in any of the original peoples of the Hawaiian Islands and Pacific Islands (for example Hawaii, Philippine Islands or Samoa). White: All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. Other: Please self define: 4. Optional: Are you an individual with a physical or mental impairment which substantially limits one or more of your major life activities? Yes No 5. Optional: Are you a Veteran? Yes No If you answered yes, please specify (Vietnam Era or other): 6. Optional: Are you a disabled Veteran? (A person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.) Yes No 7. Optional: Referral Source (how did you learn about the job?): Friend/Relative Newspaper Job Line Internet Job Posting Ohio Bureau of Employment Services Other: WE ARE AN EQUAL OPPORTUNITY EMPLOYER/SERVICE PROVIDER

3 Public Health - Dayton & Montgomery County

4 Public Health - Dayton & Montgomery County APPLICATION FOR EMPLOYMENT Applicants are considered without regard to race, color, religion, sex, national origin, age, disability, marital or veteran status. (Print clearly. Use ink. Answer all questions.) Return to: Office of Human Resources Public Health - Dayton & Montgomery County Full time 117 South Main Street Part time Dayton, Ohio Job Line: (937) Position applying for Available for: Date available GENERAL INFORMATION: Last First Middle Current Address Number Street City State Zip Telephone Number: Home Alternate Have you worked for Public Health - Dayton & Montgomery County previously? Yes No If yes, when? Do you have any relatives currently employed by Public Health - Dayton & Montgomery County Yes No If yes, what department? Are you 18 or over? Yes No Check one: U.S. Citizen Legal Resident Would you be able to work overtime, if necessary? Yes No Do you have the availability of a car for use on the job, if necessary? Yes No Do you have a valid driver's license? Yes No State Issued by Number Expiration Date Type

5 Have you ever been convicted of any crime for the violation of any law except minor traffic violations? Yes No If yes, provide the following information: Date Conviction Place Current Status Note: Convictions are not an automatic bar to employment. Each case is considered on its own merit. Do you use nicotine/tobacco in any form including replacement therapy products and prescription medications used to treat smoking addiction? MILITARY SERVICE Yes No Branch of Service Training or education while in service Reserve or National Guard Status Rank EDUCATION Circle the highest grade of school completed: Do you have a high school diploma? Yes No G.E.D.? Yes No College: College: Business/Technical: Military/Correspondence: Number of years completed Are you currently enrolled? Did you graduate? Course of study Give types of degree, credits earned, or other documents awarded. Professional license/registration/certification: Type State issued by Number Expiration date Skills: Typing wpm Computer Software Programs Office machines Other

6 EMPLOYMENT HISTORY Account for all time for the past ten years, including periods of unemployment. Begin with your present position or occupation. Indicate name used if other than signature on this application. (If you need more room, use a separate sheet of paper.) A resume will become an official part of the application, but may not be substituted for any part of this application. Company Supervisor's Company's Address Reason for leaving May we contact? Yes No Company Supervisor's Company's Address Reason for leaving May we contact? Yes No Company Supervisor's Company's Address Reason for leaving May we contact? Yes No Company Supervisor's Company's Address Reason for leaving May we contact? Yes No

7 REFERENCES List three (3) people who have knowledge of your work abilities, skills and/or character. Do not include names of relatives or employers previously listed. Address Occupation Address Occupation Address Occupation Read the following statement before signing this document: NOTE: Public Heatlh hires only United States citizens and aliens lawfully authorized to work in the United States. Verification of identity and work authorization will be required upon hiring as a condition of employment. Certain classifications, because of the nature of the work, may require preplacement and/or periodic physical examination. As an applicant for employment with Public Health - Dayton & Montgomery County, I understand and agree that Public Health - Dayton & Montgomery County may make a thorough investigation of my past employment and activities. This may include, but is not limited to, a motor vehicle operator and police record investigations. I thereby release you, your organization, my present employer(s), past employer(s), references or others from any liability or damages which may result from the exchange of the information requested. For any applicant (including any former employee) considered for hire after January 1, 2014, use of tobacco or nicotine products in any form including replacement therapy products and prescription medications used to treat smoking addiction will automatically disqualify the applicant from being hired. Employees hired after January 1, 2014 shall not use such products at any time and upon reasonable suspicion that such employee is using a tobacco or nicotine product in any form shall be subject to mandatory testing. A positive test for nicotine shall be sufficient cause for termination of their employment. I also certify that the facts set forth herein or at any step of the employment process are true, complete and correct to the best of my knowledge. I UNDERSTAND THAT FALSE STATEMENTS OR MATERIAL OMISSIONS SHALL BE CONSIDERED SUFFICIENT CAUSE AS A BAR TO EMPLOYMENT OR GROUNDS FOR DISMISSAL FROM EMPLOYMENT. Signature Date WE ARE AN EQUAL OPPORTUNITY EMPLOYER/SERVICE PROVIDER Revised 12/13

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