Fillable APPLICATION FOR EMPLOYMENT (Georgia.gov)

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APPLICATION FOR EMPLOYMENT (Georgia.gov)

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STATE OF GEORGIA
APPLICATION FOR EMPLOYMENT
An Equal Opportunity Employer
Daytime Telephone Number E-mail Address
-
-
Last Name
First Name
Street or Mailing Address
City
State
Zip Code
County
EMPLOYMENT ELIGIBILITY: To be employed by the State of Georgia, you must meet certain State and Federal employment eligibility requirements.
These include (but are not limited to) United States citizenship or authorization to work in this country, positive rehire status if previously employed by the State, and no
felony convictions (for some jobs). Please answer the following questions.
1. Are you a United States citizen?
YES NO
2. Are you an alien authorized to work in
the United States?
YES NO N/A
3. Have you ever been dismissed from any
State of Georgia government position?
YES NO
If YES, attach an explanation.
4. Have you ever been convicted
of a felony?
YES NO
If YES, attach an explanation.
TYPE OF WORK: JOB TITLE AND JOB CODE REQUIRED. If you do not know the correct job titles, information is available at the various State of Georgia
agency personnel offices, the Georgia Merit System Office in Atlanta, the Georgia Department of Labor Career Centers, or on thejobsite.org.
Specific Job Title Sought
Job Code
Specific Job Title Sought
Job Code
1.
2.
EDUCATION:
High School Graduate or
Equivalent (GED)?
Yes No
Vocational/Business School:
No. of
Months:
Field of Study:
Completed: Yes No
Date:
(Mo/Yr)
PLEASE LIST EXACT COLLEGE HOURS :
CREDIT
RECEIVED
FIELD/AREA OF CONCENTRATION
TYPE OF
DEGREE
DATE
DEGREE
COMPLETED
COLLEGES/UNIVERSITIES CITY and STATE
Qtr
Hrs
Sem
Hrs
Major Hrs Minor Hrs
(BA/BS/
MA/PhD)
(Mo./Yr.)
GEORGIA LICENSES AND CERTIFICATIONS:
Type of License/Certificate
License/Certificate
Number
Expiration
(Mo./Yr.)
Specialization/
Endorsements
Current Valid Driver’s License Yes No
Current Valid Commercial Driver’s License (CDL): Class (Check One): A B C
Teacher Certified in Georgia: Type of Certificate Held:
Georgia Peace Officer Standards and Training Certificate (POST)
Other Professional License/Certificate:
CERTIFICATION: Read carefully before signing and dating. Unsigned applications will not be processed.
I certify that all information on this application is correct. I authorize any agent or employee of the State to verify this information and to release it to
anyone who may consider me for appointment. I understand that intentionally providing false information on this form or attachments is a violation of state
law. I also understand that applications submitted electronically, via e-mail or similar media, are not valid unless I enter my name in the
signature field below and such action shall constitute an electronic signature. I further certify that either: 1) I have not been convicted of a drug-
related criminal offense; or 2) if I have been convicted of a drug-related criminal offense, it has been more than three (3) months since my first conviction,
or more than five (5) years since a second or subsequent conviction (O.C.G.A. 45-23 et. Seq.).
Signature: Date:
Georgia Merit System, P.O. Box 347100, Atlanta, GA 30334 (MS27-1) Rev. 09/03
LANGUAGE SKILLS: Check any which apply to you.
Multilingual (Specify languages)
Sign Language
click to sign
signature
click to edit
Georgia Merit System, P.O. Box 347100, Atlanta, GA 30334
2
(MS27-1) Rev. 09/03
WORK HISTORY: Describe your work history below beginning with your current or most recent job. Include military and volunteer experience. If you
worked for the same employer but held different jobs describe each separately. Describe in detail the specific duties beginning with your primary duties. If you
need more space, print out the supplemental work history page and attach to the application. Failure to give complete and detailed information regarding each job
held may result in your disqualification from employment consideration. You may submit a resume to document your work background.
However, if the resume
does not contain all the information requested in the Work History section, please fill in that information on the application.
Current or Last Employer:
Your Job Title:
Address
From (mo/yr)
To (mo/yr)
Hours per Week:
City
State
Zip Code
Check all that apply:
Volunteer Intern Paid
Annual Salary
Your Supervisor’s Name and Title
May We Contact Employer?
YES NO
Your Supervisor’s Phone Number
( )
Reason for Leaving
# and types of employees you supervised:
Describe in detail your job duties.
Related Computer Skills:
Employer:
Your Job Title:
Address
From (mo/yr)
To (mo/yr)
Hours per Week:
City
State
Zip Code
Check all that apply:
Volunteer Intern Paid
Annual Salary
Your Supervisor’s Name and Title
May We Contact Employer?
YES NO
Your Supervisor’s Phone Number
( )
Reason for Leaving
# and types of employees you supervised:
Describe in detail your job duties.
Related Computer Skills :
Employer:
Your Job Title:
Address
From (mo/yr)
To (mo/yr)
Hours per Week:
City
State
Zip Code
Check all that apply:
Volunteer Intern Paid
Annual Salary
Your Supervisor’s Name and Title
May We Contact Employer?
YES NO
Your Supervisor’s Phone Number
( )
Reason for Leaving
# and types of employees you supervised:
Describe in detail your job duties.
Related Computer Skills :
Georgia Merit System, P.O. Box 347100, Atlanta, GA 30334
3
(MS27-1) Rev. 09/03
STATE OF GEORGIA EMPLOYMENT AVAILABILITY CODES
For the job(s) listed on page 1, please select the county or counties in which you are willing to work. You may choose up to ten (10) counties, or
choose to be available for all counties by marking “Statewide” (160). For your convenience, the counties have been sorted alphabetically by
geographical region.
Where do you want to work? List up to ten (10) counties in the blanks below. Use the three digit number codes listed next to each County.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Metro Atlanta Regions
South Georgia Regions
N Metro Atlanta (E)
033 Cobb
044 Dekalb
048 Douglas
060 Fulton
067 Gwinnett
122 Rockdale
S Metro Atlanta (H)
031 Clayton
056 Fayette
060 Fulton
075 Henry
126 Spalding
Savannah Area (N)
15 Bryan
16 Bulloch
025 Chatham
051 Effingham
082 Jenkins
124 Screven
Albany Area (O)
019 Calhoun
030 Clay
047 Dougherty
088 Lee
118 Quitman
120 Randolph
128 Stewart
129 Sumter
135 Terrell
152 Webster
Tifton Area (P)
009 Ben Hill
012 Bleckley
040 Crisp
45 Dodge
46 Dooly
077 Irwin
116 Pulaski
137 Tift
142 Turner
156 Wilcox
159 Worth
Baxley Area (Q)
001 Appling
003 Bacon
034 Coffee
080 Jeff Davis
103 Montgomery
134 Telfair
138 Toombs
153 Wheeler
Reidsville Area (R)
021 Candler
054 Evans
089 Liberty
091 Long
098 McIntosh
132 Tattnall
SW GA (S)
004 Baker
014 Brooks
035 Colquitt
043 Decatur
049 Early
065 Grady
100 Miller
101 Mitchell
125 Seminole
136 Thomas
Valdosta Area (T)
002 Atkinson
010 Berrien
032 Clinch
037 Cook
050 Echols
086 Lanier
092 Lowndes
SE GA (U)
013 Brantley
020 Camden
024 Charlton
063 Glynn
113 Pierce
148 Ware
151 Wayne
North Georgia Regions
Rome Area (A)
008 Bartow
023 Catoosa
027 Chattooga
041 Dade
057 Floyd
064 Gordon
105 Murray
146 Walker
155 Whitfield
N Central GA (B)
028 Cherokee
042 Dawson
055 Fannin
058 Forsyth
061 Gilmer
093 Lumpkin
112 Pickens
144 Union
NE GA (C)
006 Banks
059 Franklin
68 Habersham
69 Hall
119 Rabun
127 Stephens
139 Towns
154 White
W GA (D)
022 Carroll
071 Haralson
110 Paulding
115 Polk
Athens Area (F)
007 Barrow
029 Clarke
052 Elbert
073 Hart
078 Jackson
095 Madison
108 Oconee
109 Oglethorpe
147 Walton
Central Georgia Regions
LaGrange Area (G) Middle GA (L)
038 Coweta 005 Baldwin
074 Heard 011 Bibb
099 Meriwether 039 Crawford
141 Troup 076 Houston
Covington Area (I) 084 Jones
018 Butts 085 Lamar
066 Greene 102 Monroe
070 Hancock 111 Peach
079 Jasper 114 Pike
104 Morgan 143 Twiggs
107 Newton 145 Upson
117 Putnam 158 Wilkinson
Columbus Area (K) Augusta Area
(J) 026 Chattahoochee 017 Burke
072 Harris 036 Columbia
094 Macon 062 Glascock
096 Marion 081 Jefferson
106 Muscogee 090 Lincoln
123 Schley 097 McDuffie
130 Talbot 121 Richmond
133 Taylor 131 Taliaferro
149 Warren
157 Wilkes
Dublin Area (M)
053 Emanuel
083 Johnson
087 Laurens
140 Treutlen
150 Washington
Statewide
160 Statewide
You will be considered for
vacancies in ALL counties of the State. Please only
choose Statewide if you
are seriously considering
relocating to any county in the State. Also be aware
that relocation at your own expense may be necessary.
Georgia Merit System, P.O. Box 347100, Atlanta, GA 30334
4
(MS27-1) Rev. 09/03
EVALUATION PROCEDURES
Written Tests: To obtain a job in certain fields, such as criminal justice and secretarial, you must pass a written and/or performance test. The tests are offered on the
following basis. Proper identification with your picture and signature, such as a driver’s license, is required for admission to all examinations.
Walk-in Examinations: Tests are offered on selected days in Atlanta only on a walk-in basis. If you wish to test in Atlanta, apply online or bring a completed
application with you. Some testing outside of Atlanta is also done on a walk-in basis. The “Walk-In Testing Schedule” is available on our Web site at thejobsite.org.
You may also call (404) 656-2724 and request a copy of this schedule.
Scheduled or Reserved Seating Examinations: Written tests are offered on certain Saturdays in selected cities. If you request a scheduled examination and
your application is approved, you will receive an admission slip by mail for the next available test session showing the address of the testing center you have chosen
and the date and time of your appointment. This may take a month or longer due to limited seating.
Select ONE city where you wish to take a written test on Saturday:
Americus - [Y] Augusta - [S] Gainesville – [F] Milledgeville - [M]
Rome - [E] Savannah - [H] Thomasville - [U] Waycross - [L]
Retest Policy: Your score will normally remain on the list of available applicants for six months from the date of your examination (and, in many cases, you may also
extend your score for an additional six months). Generally, you can apply to be evaluated or to take a written test for the same job only three times in one year, with a
minimum 30 day waiting period between examinations. Upon re-examination, the higher of your scores will generally be kept. The lower score will not be accessible to
employing agencies.
ACCOMMODATIONS FOR APPLICANTS WITH DISABILITIES
For Merit System Walk –in or Scheduled testing purposes only, do you require special examination accommodations because of a
disability?
If so, attach a note to this application asking us to call. PRIOR ARRANGEMENTS ARE NECESSARY. Note that in
order to receive accommodations for testing, you must (1) tell the Merit System you need an examination accommodation at least one
(1) day PRIOR to the test; (2) have the accommodation authorized BEFORE being tested; and (3) provide documentation to show the
need for the accommodation (if requested by the Merit System). If you have questions about the examination procedure for applicants
with disabilities, you may call the Georgia Merit System at (404) 656-2728 (TTY available) or the Georgia Relay Service at 7-1-1.
Training and Experience Ratings
:
If you apply for a job that does not require a written test, your evaluation will be based on the experience, education, and
training you describe on your application. You will also be evaluated on any supplemental information you may be asked to provide.
How You Heard About The Job:
Walk-in
College/University
Technical School
Employee Referral
thejobsite.org
Newspaper
State Agency Web Site
Other Internet Source
DOL Career Center
Other
Date: Requisition Number (for announced jobs only):
EQUAL EMPLOYMENT OPPORTUNITY INFORMATION
The information you give in this section is optional. It is used by the Georgia Merit System and other state agencies to
comply with Federal guidelines for monitoring the equal employment opportunity efforts of the State of Georgia.
Last Name
First Name
MI
Ethnic Background (Check One): Gender Birth Date
1. Native American 2. White, not of Hispanic origin (Check One):
MO DAY YR
3. Hispanic 4. Black, not of Hispanic origin Male
5. Asian/Pacific Islander 6. Multi-racial Female
Birth Date - Required for
some law enforcement
jobs.
7. Other
For Agency Use
VETERAN’S PREFERENCE:
The laws of the State of Georgia require that points be added
to passing examination scores for certain veterans and
combat troops of the Armed Forces of the United States. The following types of preference are currently granted.
If you want to apply fo
r Veteran’s Preference, check
the type below and attach copies of the appropriate document(s) to your application. Copies cannot be returned. (SPB 16.102)
VETERAN: DD214 showing dates of service and type of discharge
DISABLED VETERAN: DD214; certificate
of service-connected
disability (at least 10%) from the V.A. dated within the last 6
months
DECEASED VETERAN’S SPOUSE: DD214; marriage certificate;
veteran’s death certificate or casualty report
DISABLED VETERAN’S SPOUSE: DD214; marriage certificate;
disabled veteran’s documents dated within last 6 months (veteran
must have 100% disability)
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Completed 20 December 2021

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