CCHD Employment Application

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Screening test for illegal drug use is required before hiring and may be required during your employment here.
Equal access to programs, services, and employment is available to all persons. Applicants who require reasonable accommodation to participate in the application and/or interview process should notify the Human Resource Department.

Are you eligible to work in the U.S.? *
If you are under 18 can you furnish a work permit?
Have you ever been employed here before?
Is this application a request for re-employment following an extended military leave of absence from Cass County Health Dept.?
Employment desired:
Will you travel if job requires it?
Will you work weekends if required?
Will you work overtime if required?
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?
If driving is required in the job, do you have a current license?
Have you ever pleaded "guilty" or "no contest" to or been convicted of a felony?
Answering "yes" to the following question does not constitute an automatic bar to employment.  Factors such as date of the offense, seriousness, and nature of the violation, rehabilitation, and position applied for will be taken into account.  NOTE: You are not obligated to disclose sealed or expunged records of conviction or arrest or expunged juvenile records of conviction or arrest.

Employment History

Starting with your most recent employer, provide the following information
May we contact for reference?
Compensation (Starting)
Compensation (Final)

May we contact for reference?
Compensation (Starting)
Compensation (Final)

May we contact for reference?
Compensation (Starting)
Compensation (Final)

May we contact for reference?
Compensation (Starting)
Compensation (Final)

Have you ever been fired or asked to resign from a job?

Referral Source

How did you hear about us?
Do you know anyone who works for Cass County Health Department?

Educational Background

 Name and Location of SchoolNo. of Months/Years AttendedCertificates/Diplomas/Degree ReceivedSubjects studied/Major
High School
College or University
Trade, Business, or Correspondence School

Skills and Qualifications

Computer Skills


Give three names and following information for those not related to you and not previous supervisors
 NameCompany/TitlePhone (area code)/E-mailRelationship to YouYears Acquainted
Reference 1
Reference 2
Reference 3

Supporting Documents (Optional)

Application Statement

I certify that all information I have provided to the Cass County Health Department is complete and correct in order to apply for work. I understand that if any information that I have provided is found to be incomplete, misleading or false, this will be cause for denial of employment or termination of employment depending upon when it is discovered.

I authorize, the employer, its representatives, employees or agents to contact and obtain information from all references, past and current employers, public agencies, licensing authorities and educational institutions to verify the accuracy of all information provided by me in this application, résumé or during job interview. I waive any claims I may have against the Cass County Health Department, its agents, employees or representatives, for seeking, gathering and using information, in a lawful manner, in the employment process and further waive any claims I may have against all other persons, corporations or organizations who furnish such information about me.

I will be required to provide proof of identity and legal authorization to work in the United States if I am hired. Federal immigration laws require me to complete an I-9 Form. Cass County Health Department (CCHD) is an equal opportunity employer and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state, or federal law. CCHD does not discriminate in employment practices on account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service, arrest record, or any other protected status under applicable Federal, State or Local law.

I understand that this application remains current for one year. If I have not heard from CCHD within this time frame and still wish to be considered for employment, it will be necessary for me to reapply by completing a new application.

I understand that the completion of neither this application nor any other part of my consideration for employment establishes any obligation for CCHD to hire me. I understand that either CCHD or I can terminate my employment at any time, with or without cause and with or without prior notice.

By checking the box below and inserting my name, I certify that I have provided complete and truthful information on this application. I have read, fully understand and accept all terms of this Application Statement. *