Employment Application | Morrow County Health District

The Morrow County Health District is an Equal Opportunity Employer and employment decisions are made without regard to race, religion, color, sex, pregnancy, sexual orientation, genetic information, national origin and ancestry, age (where protected by law), veteran status, disability, or military status.

Even if you are submitting supplemental information with your application, all information on the Morrow County Health District Application for Employment must be complete.

Personal Information

Name*

First Middle Last

Address*

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

Home Phone*

Cell Phone or Other Contact Number

Email Address*

Social Security Number*

Social Security Numbers (SSNs) are used to match individuals with their application. Disclosure of your SSN is voluntary; however, upon employment and pursuant to Section 5101.312 of the Ohio Revised Code and certain other laws and regulations, a request for a SSN is mandatory. Your SSN may be used for purposes including but limited to the following: identification of obligors under child support orders, detection of welfare fraud, processing background checks, and tax information or general employee information.

Do you have a legal right to live and work in the U.S.?*

Yes
No

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

Emergency Contact Name*

Emergency Contact Phone*

Are you 18 years of age or older?*

Yes
No

Application Information

Employment Desired

Position(s)

Date you can start:

Salary Desired

Have you ever applied to the Morrow County Health District before?

Yes
No

If Yes, When?

Which office or department?

Have you previously worked for another Morrow County agency or Morrow County Health District?

Yes
No

If Yes, When?

Which office or department?

List any relatives employed by Morrow County Health District:

Name

Department

Relationship

The Morrow County Health District performs criminal background checks on prospective employees. The Ohio Revised Code prohibits the Morrow County Health District from hiring individuals with certain criminal records (i.e. R.C. 2921.41, R.C. 3721.121).

Education

Upon employment, the successful applicant may be required to provide proof of graduation or G.E.D.

Name and Location of School - High School or GED Courses

Highest Level Completed

Did you graduate?

Yes
No

Field of study

Name and Location of School - College or Trade School

Highest Level Completed

Did you graduate?

Yes
No

Field of study

Name and Location of School - Graduate or Business School

Highest Level Completed

Did you graduate?

Yes
No

Field of study

List special equipment or machines you can operate:

List computer software in which you have skills, including word processing, spreadsheets and database programs. Please indicate the name of the specific software:

List special clerical skills, including keyboarding and shorthand/speedwriting:

Are you a veteran?

Yes
No

If yes, which branch of service?

List Rank

Length of Service

Licenses, Registrations, and Certifications

Upon employment, the successful applicant must provide copies of all licenses/certifications required for the position.

Driver’s License – Check if CDL

CDL

License/Certification Number

State

Expiration Date

License/Certification Number

State

Expiration Date

Personal References

Persons who have known you for at least one year. Do not include former employers or relatives.

Name and Occupation

Address

Telephone

Years Known

Name and Occupation

Address

Telephone

Years Known

Name and Occupation

Address

Telephone

Years Known

Employment History

Are you currently employed?

Yes Full-time
Yes Part-time
No

Beginning with your most recent, list below present and past employment. All sections must be completed for each employer. Include additional Employment History sheets to reference your work history. Do not omit employer history.

Business Name

Address

Type of Business

Telephone

Last Supervisor's Name

Ending Salary

Full-Time
Part-Time
Temporary

Hire Date

Ending Date

Reason for Leaving

Position(s) Held

Was this a supervisory position?

How many employees did you supervise?

Describe Job Duties

May we contact this employer?

Yes
No

Business Name

Address

Type of Business

Telephone

Last Supervisor's Name

Ending Salary

Untitled

Full-Time
Part-Time
Temporary

Hire Date

Ending Date

Position(s) Held

Untitled