Jobs

INSTRUCTIONS:

1. Complete all sections of this application.
2. Initial the agreements at the bottom of the application and sign your name.

READ THE FOLLOWING POLICIES CAREFULLY BEFORE COMPLETING APPLICATION

No question on this application is used for the purpose of excluding any applicant for consideration on a basis protected by law.

BRHD Website
Walk-In
Newspaper
DWFS

Other

BRHD Employee

ANSWER EACH OF THE FOLLOWING QUESTIONS

Yes   No   1. May we contact you at work? If yes, give the best time to contact you:

Yes   No   2. Have you ever filed an application here? If yes, give date(s):

Yes   No   3. Have you ever been employed here? If yes, give dates:

to  

Yes   No   4. Are you related to any BRHD employee? If yes, Name/Relationship:

Yes   No   5. After employment, can you submit a birth certificate or other proof of U.S. citizenship or other proof of the right to remain in or work in the U.S.?

List the names and addresses of schools attended, starting with the most recent:

College/University Education

School 1

Yes   No   - Degree Received

School 2

Yes   No   - Degree Received

School 3

Yes   No   - Degree Received

Other Education/Training (Vocational, Technical or Other)

School 4

Yes   No   - Degree Received

School 5

Yes   No   - Degree Received

School 6

Yes   No   - Degree Received

Please list any additional skills which may assist you in performing the job for which you are applying including any languages you may speak and computer programs you may use proficiently.

Begin with your present or most recent job and describe all periods of employment, such as paid (full or part-time). Include volunteer (full or part time), self-employment, and/or military service. Account for your time during any intervals of unemployment, other than when attending school, in the additional section on page four.

Job 1

Full-Time   Part-Time

Yes   No   - May we contact for a reference?

Job 2

Full-Time   Part-Time

Yes   No   - May we contact for a reference?

Job 3

Full-Time   Part-Time

Yes   No   - May we contact for a reference?

Job 4

Full-Time   Part-Time

Yes   No   - May we contact for a reference?

List the names and telephone numbers of three business/work references that are not related to you.

List any additional information you would like us to consider and explain any intervals of unemployment:
If you answered “Yes” to question 6 on page 1, please explain the facts and circumstances here.

Bear River Health Department provides qualifying veterans with preference in employment. Qualifying veterans
may obtain preference by submitting as verification of eligibility, a copy of the Certificate of Release or Discharge from Active Duty (DD Form 214 or 215).

If you are a spouse of a veteran or unmarried widow/widower and wish to claim veteran’s preference, please
submit a copy of either your marriage license or DD1173 card and the DD 214 or 215 forms.

This information is voluntary. However DISCLOSURE OF THE INFORMATION IS REQUIRED IF YOU WISH TO
BE GIVEN PREFERENCE.

Do you claim Veteran’s Preference?  Yes   No

Do you claim Disabled Veteran’s Preference?   Yes   No

If yes, “x” one of the following as a/an:   Veteran   Spouse, unmarried widow or widower of a veteran

If yes, “x” one of the following as a/an:   Disabled veteran   Spouse, unmarried widow/widower of disabled veteran

I have read the instructions and application policies section on page 1 of this application.

I certify that the information in this application is true and correct to the best of my knowledge and I
understand that any misrepresentations, falsifications or omissions of information will result in my
disqualification from consideration for employment or, if employed my dismissal. I understand that this
application is not a contract, offer, or promise of employment.

I have read, understand and agree to the above statement.

I give Bear River Health Department the right to investigate all information on this application and to
secure private or confidential information about me, if job related. I authorize all persons, schools,
companies, corporations, and agencies to supply any information concerning the information on this
application. I hereby release all such parties from any liability that may result from furnishing this
information to Bear River Health Department. I also release from liability Bear River Health Department
and its representatives for seeking information concerning my employment and education background.

I have read, understand and agree to the above statement.

I understand that Bear River Health Department has a commitment to maintain an alcohol and drug-free
workplace. I further understand and agree that if I am offered employment, I will be required to submit to
an alcohol/drug testing prior to employment.

I have read, understand and agree to the above statement.

Application Signature

Attach a PDF of your resume:

Or for larger files provide a public link to DropBox, or GoogleDrive, so that we can download your files: