Employment Application Employment Application Online Job Application Step 1 of 6 16% EMPLOYMENT APPLICATIONJohnson County Community Health Services is an Equal Opportunity Employer, we do not discriminate based on race, national origin, religion, age, sex, color or physical disability. This application is designed to obtain an applicant’s skills, knowledge and abilities based on specific job requirements.Date* MM slash DD slash YYYY PERSONAL INFORMATIONName* First Middle Last Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Are you authorized to work in the United States?* YES NO Position Applying For:* Desired Salary*Date available to start:* MM slash DD slash YYYY EDUCATIONHigh School or GED Completed?*YESNOCollege, Business School, Military School Name Location Dates Attended Degree Type Please enter the most recent first. College, Business School, Military School Name Location Dates Attended Degree Type Please enter the most recent first. College, Business School, Military School Name Location Dates Attended Degree Type Please enter the most recent first. Credentials/ License/Certification: Type of Cerdentials/License/Cert Number Where Issues Expiration Date Credentials/ License/Certification: Type of Cerdentials/License/Cert Number Where Issues Expiration Date Microsoft Office Skills YES NO Other Skills EMPLOYMENT HISTORYPresent or Most Recent Employer* Company Job Title Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Supervisor* First Last May we contact?*YesNoEnding Salary:*Dates worked here:* Reason for leaving:* Describe job duties:*Employment History ContinuedPrevious Employer* Company Job Title Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Supervisor* First Last May we contact?*YesNoEnding Salary*Dates worked here:* Reason for leaving:* Describe job duties:*Employment History ContinuedPrevious Employer* Company Job Title Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Supervisor* First Last May we contact?*YesNoEnding Salary:*Dates worked here: Reason for leaving:* Describe job duties:* Have you ever been employed at JCCHS?*YESNOIf yes, what is their relationship? MM slash DD slash YYYY Do you have relatives employed at JCCHS?*YESNOIf Yes, what is their relationship? Do you have any restrictions to operate a motor vehicle? YES NO Do you have a valid driver's license? YES NO REFERENCESGive three references, preferably business or professional. No relatives.First Reference*NameAddressPhoneOccupation/BusinessEmail Second Reference*NameAddressPhoneOccupation/BusinessEmail Third Reference*NameAddressPhoneOccupation/BusinessEmail ResumeMax. file size: 256 MB.Cover LetterMax. file size: 256 MB. Electronic SignatureI certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Please select:*AGREEDISAGREEName* First Last By typing your full name above, you are electronically signing this agreement.Date* MM slash DD slash YYYY Δ