Last Name   First Name   Middle Name

Present Address   

Telephone Number    Alternate Telephone Number 

City    State    Zip Code    Social Security # 

Position(s) Applying For: 

Availability for Employment: Do you want to work:  Full time  or Part Time

Enter your schedule here

If hired, how soon could you begin work?  Minimum Salary Acceptable

Note:  If you wish you may e-mail us your resume to personnel@elkhartcounty.com - how ever, please answer all inquires.

EDUCATION

    A. List all high schools and universities attended.  If requested, attach transcripts.  List other schools or training (trade, vocational, business, or military).

    B.  Give a brief description of your major course of study.

EMPLOYMENT HISTORY             Begin with your current job.   

Where you ever Discharged or Forced to Resign from any position?  Yes  No                                                                              

If Yes, Why?

May we refer to your Previous Employers?  Yes  No  If No, Which Employer and why?

May we refer to your Present Employer?  Yes  No

Have you previously worked for Elkhart County?  Yes  No  If so, what department? 

Reason for leaving 

SPECIAL KNOWLEDGE, SKILLS AND ABILITIES

List any appropriate knowledge or skills you may have relevant to your position interests.

    A.  Indicate clerical skills you possess and office equipment you can operate.

        Skills:

        Words per minute:    Typing    Shorthand 

                                        Tape Transcription 

                                        Special Terminology    Medical  Legal  Statistical 

        Equipment:

        Word Processing        Computer    Calculator          By Touch   By Sight 

Please indicate Type of Equipment and Software

Telephone Switchboard              Type 

                                                       Number of Lines 

    B.  Indicate trade skills you possess, machinery you can operate and other special technical capabilities.

    C.  Indicate any special professional and/or paraprofessional skills, knowledge or licenses you have.

CONVICTIONS

Have you ever been convicted of an infraction (such as speeding tickets), a misdemeanor or felony? 

Yes  No

If Yes, list charge, date, place of conviction and other details.                                                                                                 

PLEASE NOTE:

            A conviction record will not necessarily be a bar to employment.  Factors such as age, time of offense, seriousness

            and nature of violation, and rehabilitation will be taken into consideration.

If you are applying for a position that requires operation of a motor vehicle, please complete the following section:

Give the following information concerning any operator’s license that you have held or now hold.        

 Give Name and Address of the Insurance Company with whom you now have automobile insurance.

Within the last five (5) years have you - been denied issuance of a license?          Yes  No

                                                          - had a license suspended or revoked?     Yes  No

                                                          - been denied automobile insurance?        Yes  No  

                                                          - had insurance withdrawn or revoked?    Yes  No

If the answer to any of the above questions is "Yes", explain in full:

The Federal Government requires the following information be collected in order to for us to

demonstrate compliance with Equal Employment Opportunity and Affirmative Action. This data

sheet will be detached from your Application for Employment by the Personnel Department and

will in no way be used to make employment decisions or for other employment purposes.

We do appreciate your providing us with this information and thank you for assisting us in our data

collection efforts.

PERSONAL DATA

Name   Date of Application

Date of Birth  Sex male female

Position Applied For/Department  

REFERRAL SOURCE

Where did you hear about the job opening you are applying for?  Please check one.

Other Newspaper (specify)               

Private Employment Agency (specify)

Community Agency (specify)             

Other - Not Listed above (specify)    

ETHNIC GROUP Please check one.

VETERANS STATUS

Are you a veteran of any branch of the U.S. Armed Forces?

Yes      No

If Yes, Branch

Please read the following paragraphs before submitting the application below.

        By submitting this application I acknowledge receipt of the “Notice to Applicants for Elkhart County Employment – Group Health Plan.”

        A false answer to any question in this application may be grounds for not employing you, or for dismissing you

after you begin work. All the information you give will be considered in reviewing your application and is subject

to investigation.

        “I certify that all the statements made in this application are true, complete and correct to the best of my

knowledge and belief, and are made in good faith. I authorize my previous employers, schools or persons named

to give Elkhart County any information regarding my employment or educational background. I grant my

permission for any investigation of the information I have provided in this application. I further understand the

information is job-related and non-discriminatory.”

ELKHART COUNTY, INDIANA
Employee HIPAA Opt Out Notification
2009

Under a federal law know as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, as amended, group health plans must generally comply with the requirements listed below. However, the law also permits State and local governmental employers that sponsor health plans to elect to exempt a plan from these requirements for any part of the plan that is "self-funded" by the employer, rather than provided through a health insurance policy. Elkhart County, Indiana has elected to exempt from the following requirements:

Elkhart County, Indiana is eligible to opt out of certain provisions of the Health Insurance Portability and Accountability Act, and has elected to do so, as detailed below:

1.         Limitations on preexisting condition exclusion periods. A preexisting condition exclusion period generally may not exceed 12 months, and generally must be reduced by prior health coverage an individual has had. Also, a plan may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition, nor, under certain conditions, with respect to newborns or children adopted or placed for adoption.

The pre-existing limitation period for Elkhart County will continue to be 6 months for an employee (or 3 months treatment free) and 12 months for a dependent.

2.         Prohibitions against discriminating against individual participants and beneficiaries based on health status. A group health plan may not discriminate in enrollment rules or in the amount of premiums or contributions it requires an individual to pay based on certain health status-related factors: health status, medical condition (physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.

If you do not apply for coverage when eligible, you will be required to provide evidence of insurability to be accepted for coverage. Based on the information you provide, you may be declined for coverage.

The exemption from these federal requirements will be in effect for the 2009-2010 plan year beginning February 1, 2009 through January 31, 2010. The election may be renewed for subsequent plan years.

HIPAA also requires the Plan to provide covered employees and dependents with a "certificate of creditable coverage" when they cease to be covered under the Plan. There is no exemption from this requirement. The certificate provides evidence that you were covered under this Plan, because if you can establish your prior coverage, you may be entitled to certain rights to reduce or eliminate a pre-existing condition exclusion if you join another employer's health plan, or if you wish to purchase an individual health insurance policy.

If you have any questions regarding this notice, please contact the Elkhart County Personnel Office. Thank you.