Community Health Specialist

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Please complete the form below to apply for this position.

* First Name:
* Last Name:
Address:
City:
State/Province:
Country:
Zip Code:
* Email Address:
Phone Number:
Fax Number:
Resume Upload:
Cover Letter Upload:
Referral Source (Please provide detail when possible):
Newspaper:
Web site:
Professional Journal:
Employee:
Bulletin Board:
Walk-in:
Other:
If other please list:
* List any relatives employed by or serving as elected or appointed officials of Langlade County and their relationship to you.
(Langlade County may prohibit employment of an individual if he or she would be directly supervising or receiving direct supervision from a family member.) :
* Position you're applying for:
* Department:
* Date available for work?
* Have you ever been employed by or applied for employment with Langlade County?
Yes
No
If yes, when, in what position and what department?
* Are you employed now?
Yes
No
If yes, please list current employer:
* If hired, would you be available to work overtime?
Yes
No
* If hired, would you be able to work nights and or weekends? "Reasonable accomodation will be made for religious beliefs or practices, unless doing so would create an undue hardship on the operations of the county.":
Yes
No
* Type of Employment Acceptable; (check all that apply):
Full-time
Part-time
Seasonal
Casual
* Are you at least 18 years of age? (Employment may be subject to verification that you meet state and federal minimum age requirements. Employees under 18 shall have a work permit):
Yes
No
* Are you a United States citizen, or do you have papers from the U.S. government permitting you to work? (Verification will be required at the time of employment):
Yes
No
* Are you able to perform all of the duties listed in the position description, with or without reasonable accomodation?
Yes
No
A 'yes' answer to any of the following questions does not necessarily disqualify an applicant from the selection process.
If you answered 'yes' to any of the following questions,please provide an explanation.:
* Have you ever been convicted of an ordinance violation, misdemeanor, or felony?
Yes
No
If yes, please explain:
* Have you ever been suspended, terminated discharged or resigned to avoid being discharged?
Yes
No
If yes, please explain:
* Have you had periods in which you were not employed during the last 10 years?
Yes
No
If yes, please explain:
* High School Highest Level Completed:
9
10
11
12
GED/HSED
Name and Location of High School:
* Graduated?
Yes
No
Education and/or Training Beyond High School
(Please list Name and Location of Institution, Dates Attended, Major Field of Study, GPA and Degree Conferred/Year
 :
Please list relevant coursework or Additional Skills/Training:
Special Skills (If any boxes are checked please explain below):
Word Processing
Data Entry
Calculator
Software Packages
Database/Programming Languages
Professional licensures/certifications
Heavy Equipment
Other
Please explain any special skills here:
* Do you have a vehicle available for work related business?
Yes
No
* Do you have a valid drivers license?
Yes
No
If yes, please enter the state issued and the drivers license number::
* If the position requires, do you have a valid Wisconsin Commerical Driver's license (CDL)?
Yes
No
If yes, please list endorsements:
* List any moving violations withinin the previous five (5) years: "A violation or conviction will not necessarily disqualify you from employment. It will be considered only as it may relate to the job you are seeking.":
* Do you have or can you make arrangements to obtain vehicle insurance coverage?
Yes
No
* Please provide four (4) professional references that would be able to describe your work abilities, qualifications, skills, and/or educational background. Please DO NOT submit the names of friends, relatives, spouses, or significant others.

Please provide Name, Telephone number, Occupation, and Nature of Relationship for reach reference.:
* Please provide your work history. For each employer list Employer Name, Position Title, Type of Business, Address of Business (street, city, ZIP), Reason For Leaving, Name, Title & Phone of Supervisor, Employment Dates (From - To), Starting Salary, Ending Salary, Hours Per Week and Description of Duties.:
* May we (Langlade County) contact past employers prior to an offer of employment?
Yes
No
*
LANGLADE COUNTY AUTHORIZATION TO RELEASE INFORMATION AND ACKNOWLEDGMENT FOR EMPLOYMENT

I have carefully reviewed the job description for the position I have applied for. I certify that I completely understand the physical/mental requirements and the environmental factors of the job I am applying for. I certify that I am physically and mentally capable of performing the functions of the job I am applying for with or without the following accommodations (leave blank if no accommodations are necessary):

 :
* I have read the employment application and I completely understand each and every question asked. I certify that the answers given by me in the application are true and correct without omissions of any kind. I understand that any misleading or incorrect statements may render this application void. If I am employed and it is subsequently discovered that any answer given by me is incomplete, misleading or incorrect, my employment with Langlade County may be terminated. I agree that Langlade County shall not be held liable in any respect if my employment is terminated because of false, incomplete or misleading statements, answers or omissions made by me in this application. I also authorize pertinent former employers, companies, schools, agencies, municipalities or persons to give to Langlade County any information requested regarding my employment, character, experience and qualifications, and/or suitability for employment, including a check of my fingerprints, police record and background for purposes of considering my suitability for hire. I hereby forever release, discharge and covenant not to sue any person or organization for any result of providing, obtaining or acting upon such information. I understand that such information is sought with confidentiality and will not be released to me in any form whatsoever. I further understand that to ascertain my eligibility for employment I may be asked to undergo a physical examination, which may include substance abuse screening (drug testing), prior to employment with Langlade County. Refusal to participate in such examination will result in the rejection of my application. A copy of this authorization is as valid as the original and should be recognized as such.

Please enter your name and today's date in the text box (This is your digital signature)
 :
*
Open Records Disclosure (Optional)

This section is optional: Under Section 19.36 (7) of the Wisconsin Statutes, the names of “final candidates” must be open to public inspection. The statute also provides that if an applicant does not want his/her name revealed prior to being a “final candidate” they can do so by making a request in writing. Accordingly, I hereby request that my employment application and all related information references and documents remain confidential to the extent allowed by Wisconsin Statutes.

Thank you for completing this application and for your interest in employment with Langlade County.

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* Required Field

Equal Opportunity Employer