Employment Application | Northern Apache Coun

Position

Date

Personal Information

Name:

Other Names Used if Applicable:

Date of Birth:

Address:

Driver License Number

Type:

CDL

Operator

Class

State

Expiration Date:

Telephone Number:

Message Number:

Email Address:

Are you an enrolled member of the Navajo tribe:

Yes

No

If yes, indicate census number:

If no, state nationality

Are you a spouse of an enrolled member of the Navajo tribe:

Yes

No

If yes, indicate spouse name and census number:

Education:

High School:

Dates Attended:

Received:

GED

DIPLOMA

Degree

Major/Minor:

College/University:

Dates Attended:

Received:

GED

DIPLOMA

Degree

Major/Minor:

College/University:

Dates Attended:

Received:

GED

DIPLOMA

Degree

Major/Minor:

Technical/Vocational/Business School:

Dates Attended:

Received:

GED

DIPLOMA

Degree

Major/Minor:

List Additional Credentials, Certifications And Job Related Training - Include Dates of Training:

List Job Related Skills:

References:

List three persons who are not related to you and have definite knowledge of your qualifications for the position you are applying for. Do not repeat names of supervisors listed under work history.

Name:

Email Address:

Telephone Number:

Name:

Email Address:

Telephone Number:

Name:

Email Address:

Telephone Number:

Additional Employee Information:

Have you ever been convicted of a felony?

Yes

No

If yes, give date and reason:

**A conviction does not automatically disqualify you, however, an incomplete answer will result in an incomplete application:

List any phyiscal condition(s) which may challenge your ability to perform the responsibilities of the job for which you are applying:

Are You Related to Anyone Currently Employed With, Or On The Board Of, Northern Apache County Special Health Care District?

Yes

No

Name/Department:

Relationship:

Name/Department:

Relationship: