EMPLOYMENT DESIRED:

POSITION

DATE YOU CAN START

SALARY DESIRED:

TYPE OF EMPLOYMENT: FULL-TIME: PART-TIME: SUMMER: TEMPORARY: VOLUNTEER:

ARE YOU EMPLOYED NOW? YES NO IF SO, CAN WE CONTACT YOUR PRESENT EMPLOYER? YES NO

HAVE YOU EVER APPLIED TO THE NORTHEAST TEXAS PUBLIC HEALTH DISTRICT BEFORE? YES NO

WHERE?: WHEN?:

Personal Information:

LAST NAME:

FIRST NAME:

MIDDLE:

ADDRESS:

SOCIAL SECURITY NO.
- -

TELEPHONE NO.:

REFERRED BY:

HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES NO

EDUCATION:

HIGH SCHOOL ATTENDED AND LOCATION:

No. of Years Completed: Did you Graduate? YES NO

COLLEGE ATTENDED AND LOCATION:

No. of Years Completed: Did you Graduate? YES NO DEGREE

TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL ATTENDED:

No. of Years Completed: Did you Graduate? YES NO

GENERAL:

SPECIAL COURSES OR TRAINING:

EXPERIENCE/SKILLS RELATED TO THE POSITION FOR WHICH YOU ARE APPLYING:

OFFICE/SECRETARIAL APPLICATIONS:

TYPING:

YES NO

YEARS OF EXPERIENCE:

WORDS PER MINUTE:

SHORTHAND:

YES NO

YEARS OF EXPERIENCE:

WORDS PER MINUTE:

WORD PROCESSING:

YES NO

YEARS OF EXPERIENCE:

WORDS PER MINUTE:

SOFTWARE:

LIST SECRETARIAL TRAINING COURSES OR ANY OTHER TRAINING WHICH MAY BE HELPFUL IN CONSIDERING YOUR APPLICATION:

EMPLOYMENT HISTORY (LIST PRESENT OR MOST RECENT POSITION FIRST):

NAME OF EMPLOYER:

TELEPHONE:

ADDRESS: (INCLUDE STREET, CITY, STATE, ZIP):

TYPE OF BUSINESS: DEPARTMENT: YOUR POSITION:

DUTIES:

NAME AND POSITION OF IMMEDIATE SUPERVISOR:

DATE HIRED: DATE LEFT: STARTING SALARY: FINAL SALARY:

REASON FOR LEAVING:

NAME OF EMPLOYER:

TELEPHONE:

ADDRESS: (INCLUDE STREET, CITY, STATE, ZIP):

TYPE OF BUSINESS: DEPARTMENT: YOUR POSITION:

DUTIES:

NAME AND POSITION OF IMMEDIATE SUPERVISOR:

DATE HIRED: DATE LEFT: STARTING SALARY: FINAL SALARY:

REASON FOR LEAVING:

NAME OF EMPLOYER:

TELEPHONE:

ADDRESS: (INCLUDE STREET, CITY, STATE, ZIP):

TYPE OF BUSINESS: DEPARTMENT: YOUR POSITION:

DUTIES:

NAME AND POSITION OF IMMEDIATE SUPERVISOR:

DATE HIRED: DATE LEFT: STARTING SALARY: FINAL SALARY:

REASON FOR LEAVING:

NAME OF EMPLOYER:

TELEPHONE:

ADDRESS: (INCLUDE STREET, CITY, STATE, ZIP):

TYPE OF BUSINESS: DEPARTMENT: YOUR POSITION:

DUTIES:

NAME AND POSITION OF IMMEDIATE SUPERVISOR:

DATE HIRED: DATE LEFT: STARTING SALARY: FINAL SALARY:

REASON FOR LEAVING:

OFFICE/SECRETARIAL APPLICATIONS:

STATE ANY ADDITIONAL INFORMATION YOU FEEL MAY BE HELPFUL TO US IN CONSIDERING YOUR APPLICATION:

Signature

ENTER YOUR NAME BELOW.