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Enter Information for Job Application

Email:
Job:

Personal Information (Page One)

Name

First:
Middle:
Last:

Address

Number:

Street:

City:

State:

Zip:

How long have you lived at this address? Telephone:

Alternate Phone Number: Previous Address:

Number:

Street:

City:

State:

Zip:

How long have you lived at this address?

Personal Information (Page Two)

Background

Are you a U.S.Citizen?

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Explain: Have you ever been convicted of a felony? If Yes, Please explain Have you interviewed with the County in the last 12 months? If so, what position Have you ever worked for Houston County before? If yes, give dates Drivers License:

Education (Page One):

Elementary

School Name

Years Completed

High School

School Name

Years Completed

Course of Study

Diploma/Degree (Year)

Education (Page Two):

College/University

School Name

Years Completed

Course of Study

Diploma/ Degree (Year)

Graduate/Professional

School Name

Years Completed

Course of Study

Diploma/ Degree (Year)

Describe Specialized training, Apprenticeship, Skills, and Extra Curricular Activities

Employment (Page One):

Employer #01

Employer

Address

Job Title

Supervisor

Reason for Leaving

Date Employed

From

To

Salary

Start

Finish

Work Performed

Employer #02

Employer

Address

Job Title

Supervisor

Reason for Leaving

Date Employed

From

To

Salary

Start

Finish

Work Performed

Employment (Page Two):

Employer #03

Employer

Address

Job Title

Supervisor

Reason for Leaving

Date Employed

From

To

Salary

Start

To

Work Performed

Employer #04

Employer

Address

Job Title

Supervisor

Reason for Leaving

Date Employed

From

To

Salary

Start

To

Work Performed

Person References

Person References (Not former employees or relatives)

Name

Phone

Address

Name

Phone

Address

Name

Phone

Address

Please Read Carefully Before Signing

I understand that all appointments are probationary for a period of six months. during which time I must demonstrate my fitness for continued employment. I also understand that all appointments offered me will be contingent upon the results of a complete character and fitness investigation. I am aware that willfully withholding information or making false statements on the application will be a basis for denial of a position prior to employment, or will be grounds for dismissal after appointment. I agree that this application and all other papers shall be confidential records of the Personnel Board subject to inspection by the appointing authority. I hereby certify that all statements are true and correct to the best of my knowledge.

Salary

Date

Signature

Person References

Authorization and Release

A FALSE STATEMENT ON ANY PART OF YOUR APPLICATION MAY BE GROUNDS FOR NOT HIRING YOU, OR FOR TERMINATION OF YOUR EMPLOYMENT AFTER YOU BEGIN WORK.

I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability and fitness of employment with Houston County by law enforcement agencies, employers, schools, and other individuals and organizations, to personnel staffingspecialists, and other authorized employees of Houston County. I certify that to the best of my knowledge and belief, all of my statements on employment applications and related employment papers are true, correct, and complete, and made in good faith.I hereby release the aforementioned person T corporations, agencies, associations and their employees, agents and representatives from any and all liability for damages of what ever kind of nature which may at any time result to me on account of compliance with this authorization.A copy of this authorization shall be effective and valid as the original.

Signature

Date of Signature
(MM/DD/YYYY)

Attention: Applicants having military experience should also read and sign the following statement: I authorize the National Personnel Records Center, St Louis, MO or other custodian/s of my military record to release to the Houston County Personnel Board, information or photocopies form my military personnel and related medical records, or only the following informationlrecords:

(Please specify)
This could include a photocopy of my Form 214, Report of Separation.

Signature of Veteran

Date of Signature
(MM/DD/YYYY)

Person References:

***Special Condition

You may inform us if you have a disablity requiring accommodation.
State any additinal information you feel would be helpful to us in considering your application.

Military Service Record

(Have you ever served in the armed forces?

(If "Yes" what branch?

From

To

Rank Discharge

List your duties in service, including special training

***Special Condition

Are you related by blood or marriage to any official, department head, or supervisor of any Houston County Department, Board. Bureau, committee. commission, institution, corporation, authority or any other agency?

If "Yes", Please state their name and title of their position.

Equal Employment Opportunity

EEO REPORTING DATA

The following information is requested for Equal Employment Opportunity record keeping and reporting compliance purposes only as specified by Title VII ofthe Civil Rights Act of 1964 as amended. This section is voluntary and will be kept confidential.

Sex

Race

Name

Date

Enter Information for Job Application

Personal Information (Page One)

Personal Information (Page Two)

Education (Page One):

Education (Page Two):

Employment (Page One):

Employment (Page Two):

Person References

Person References

Person References:

Equal Employment Opportunity

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