Form CH-36 "Application for Employment" - Kentucky

What Is Form CH-36?

This is a legal form that was released by the Kentucky Department for Public Health - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the Kentucky Department for Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CH-36 by clicking the link below or browse more documents and templates provided by the Kentucky Department for Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form CH-36 "Application for Employment" - Kentucky

Download PDF

Fill PDF online

Rate (4.6 / 5) 28 votes
CH-36 (Revised 01/2021)
APPLICATION FOR EMPLOYMENT
Local Health Departments of Kentucky
(Excluding Lexington-Fayette, Louisville Metro, and Northern Kentucky, which include Boone, Kenton, Campbell, and Grant Counties)
Department for Public Health
Division of Administration & Financial Management
Local Health Personnel Branch
Phone number (502) 564-6663
To apply to an open merit position, you must use the online
applications system at
by
https://KOG.CHFS.KY.GOV/HOME
creating a citizen account and then search LHDCOS (search and
apply). Paper applications are used for internal openings and
contracts.
INFORMATION SHEET
General Instructions for completing the application for employment:
Type or print clearly in dark ink.
 Job Announcements may contain special instructions and requirements.
 Do not substitute a resume or other application form.
 Write the job title as specified on the job announcement.
 All supporting documents, such as transcripts, must be submitted by the close date
in the advertisement to the local health department.
 Applications that are received unsigned, incomplete, or after the closing date, might
be eliminated from consideration.
1
CH-36 (Revised 01/2021)
APPLICATION FOR EMPLOYMENT
Local Health Departments of Kentucky
(Excluding Lexington-Fayette, Louisville Metro, and Northern Kentucky, which include Boone, Kenton, Campbell, and Grant Counties)
Department for Public Health
Division of Administration & Financial Management
Local Health Personnel Branch
Phone number (502) 564-6663
To apply to an open merit position, you must use the online
applications system at
by
https://KOG.CHFS.KY.GOV/HOME
creating a citizen account and then search LHDCOS (search and
apply). Paper applications are used for internal openings and
contracts.
INFORMATION SHEET
General Instructions for completing the application for employment:
Type or print clearly in dark ink.
 Job Announcements may contain special instructions and requirements.
 Do not substitute a resume or other application form.
 Write the job title as specified on the job announcement.
 All supporting documents, such as transcripts, must be submitted by the close date
in the advertisement to the local health department.
 Applications that are received unsigned, incomplete, or after the closing date, might
be eliminated from consideration.
1
CH-36 (Revised 01/2021)
EEO Survey
Although the following information is not mandatory, it is requested to aid the Department
for Public Health and the local health department in their commitment to Equal
Employment Opportunity. The information in this section will not be used in making any
decision affecting potential employment or any personnel action following employment,
should you be employed.
POSITION TITLE FOR WHICH YOU ARE APPLYING:
Gender:
Male
Female
Other
Ethnicity (Check Only One)
White (Non-Hispanic)
Black/African American
Hispanic or Latino
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
Asian
Other
2
CH-36 (Revised 01/2021)
LOCAL HEALTH DEPARTMENTS OF KENTUCKY
APPLICATION FOR EMPLOYMENT
Agency use only-----
Equal Opportunity Employer. We do not discriminate in employment on the basis of race, color, religion, sex
________Class # ________
(including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status,
.
disability, genetic information, age, membership in an employee organization, retaliation, parental status,
________Class # ________
military service, public assistance, or other non-merit factor. Thank you for your interest in employment with us.
________Class # ________
________Class # ________
-
-
Social Security
Number
Date:
SSN Required for Record Keeping and Data Processing only
Name
Last
First
Middle
(Maiden)
Present
Address
Street
City
State
Zip Code
County
Telephone (
)
-
Additional # (
)
-
Email:
POSITION (S) APPLIED FOR
Local Health Department
Local Health Department
Title of Position
Title of Position
PERSONAL INFORMATION
If under 18 years of age, please provide proof of eligibility to work.
Yes
No
Do you have a relative employed with a Kentucky local health department?
If yes, who?
Which health department?
Yes
No
May we contact your present employer?
Yes
No
May we contact your previous employer(s)?
3
Social Security No
-
-
For identification in case pages become separated
CH-36 (Revised 01/2021)
AVAILABILITY
:
If offered employment, you will be asked to verify that you are a citizen of the United States or prove that
your immigration status permits you to work.
On what date will you be available for work?
Full-time
Part-time
Temporary
Do you have a valid drivers’ license?
Yes
No
Yes
No
Are you available for travel?
Yes
No
Are you available to work on-call (after regular work hours?
Saturdays, Sundays)? *Some positions may require that you be on call on a rotating
basis to provide service after regular working hours or on the weekends.
Yes
No
Are you available to work overtime during the week?
Yes
No
Are you available to work overtime on weekends?
EDUCATION AND TRAINING
EDUCATION
High School/GED
Yes
No If no, please indicate the highest grade completed
College Graduate
Yes
No Please indicate the highest level of college completed:
College Freshman
College Sophomore
College Junior
College Senior
Associate’s Degree
Bachelor’s Degree
Master’s Degree
Ph D
Are you currently attending school?
Yes
No
If yes, anticipated graduation or completion
date:
TRANSCRIPTS MUST BE PROVIDED AT TIME OF
APPLICATION FOR THOSE JOB ANNOUNCEMENTS THAT
REQUIRE POST-SECONDARY EDUCATION OR WHEN
EDUCATION CAN BE SUBSTITUTED FOR EXPERIENCE.
.
TRANSCRIPTS MUST SHOW THE DEGREE AWARDED
4
Social Security No
-
-
For identification in case pages become separated
CH-36 (Revised 01/2021)
College, University or Professional School: List all undergraduate and graduate work.
Dates of
Attendance
(Month and
Degree
Year)
Number of
Rec’d
AA.,
BS.
Credits
Etc.
Name
Location
From
To
Qtr. Sem.
Major
Minor
Date
Dates of
Attendance
(Month and
Business, Correspondence,
Trade, Technical, or
Year)
Vocational School
Total Hours
Hours Required
Courses/Subjects
Name and Location
From
To
Completed
for Certification
Taken
Certificates Received
LICENSES OR CERTIFICATES:
Please indicate if you have a license, certificate, or other authorization to practice a trade or profession.
A COPY OF LICENSURE VERIFICATION IS REQUIRED FOR POSITIONS, E.G., NURSE,
*
PHYSICAL THERAPIST, ARNP, ETC.
License
Current License
Name and Address of Licensing
Verified
Number
Expiration Date
Agency
Name of Trade or Profession
*
Certificate/License:
KNOWLEDGE / SKILL/ ABILITIES (KSAs)
List KSAs you possess and believe relevant to the position you seek, such as operating a computer, fluency in a language, etc.
5