Fillable APPLICATION FOR EMPLOYMENT Print in black ink or (Missouri)

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APPLICATION FOR EMPLOYMENT Print in black ink or (Missouri)

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Woodrail Centre
1000 West Nifong, Bldg. 7, Ste. 100
Phone: (573) 777-9977
Columbia, MO 65203-5661
Fax: (573) 777-9976
TTY/TTD (Hearing/Speech Impaired): (800) 735-2966
www.publicdefender.mo.gov
Human.Resources@mspd.mo.gov
ENTER YOUR NAME HERE: Last Name: ____________________________ First Name: ___________________ Middle Initial: _________
APPLICATION FOR EMPLOYMENT
________________________________________________________________________________________________________________________________________________________________
Print in black ink or type answers to every question. All sections of the application must be completed.
Submit the application to the mailing address, fax number, or email address above. Individuals with disabilities should contact Human
Resources at (573) 777-9977 if accommodations or assistance is needed in any phase of the employment process.
PERSONAL DATA
LAST NAME FIRST NAME MIDDLE INITIAL
SOCIAL SECURITY NUMBER OTHER NAMES IN WHICH RECORDS MAY BE FOUND PREFERRED NAME, IF DIFFERENT
PERMANENT ADDRESS (number & street) CITY STATE ZIP PHONE
TEMPORARY ADDRESS (if applicable) CITY STATE ZIP PHONE
EMAIL ADDRESS ALTERNATE CONTACT PHONE NUMBER MAY WE CONTACT YOU AT WORK?
YES
NO
POSITION APPLIED FOR (please be specific)
EARLIEST EMPLOYMENT DATE AVAILABLE:
ON OR AFTER (Date):
AFTER TWO-
WEEK NOTICE
TYPE OF POSITION WILL CONSIDER:
FULL TIME PART TIME
SPECIFY DAYS & HOURS IF PART TIME
HAVE YOU EVER WORKED IN A PAID,
CONTRACT, CLINICAL, OR VOLUNTEER
CAPACITY WITH OUR AGENCY?
YES NO
IF YES, LIST THE NATURE OF POSITION, OFFICE LOCATION, AND APPROXIMATE DATES OF EMPLOYMENT
HAVE YOU EVER WORKED FOR ANOTHER
STATE AGENCY IN MISSOURI?
YES
NO
IF YES, LIST THE DATES OF EMPLOYMENT AND AGENCY
NAMES OF ANY RELATIVES EMPLOYED BY THIS AGENCY
(NAME) (RELATIONSHIP)
PLEASE CHECK ALL LOCATIONS YOU WILL CONSIDER FOR EMPLOYMENT
COMMENTS/INFORMATION
ABOUT LOCATION PREFERENCE:
CENTRAL REGION: EASTERN REGION: NORTHERN REGION:
SOUTHEASTERN
REGION:
SOUTHWESTERN
REGION:
WESTERN REGION:
Columbia
Fulton
Jefferson City
Moberly
Sedalia
Farmington
Hillsboro
Rolla
St. Charles
St. Louis City
St. Louis County
Troy
Union
Chillicothe
Hannibal
Kirksville
Maryville
Cape Girardeau
Portageville
Kennett
Poplar Bluff
West Plains
Ava
Bolivar
Carthage
Lebanon
Monett
Springfield
Harrisonville
Kansas City
Liberty
Nevada
St. Joseph
Print Form
EDUCATION
HIGH
SCHOOL
NAME & LOCATION OF SCHOOL
HIGH SCHOOL GRADUATE
OR HIGH SCHOOL
EQUIVALENCY
YES
NO
COLLEGE/
PROFESSIONAL &
OTHER SPECIAL
TRAINING
NAME & LOCATION OF SCHOOL FROM TO
MAJOR/
MINOR
DEGREE (OR HIGHEST
GRADE COMPLETED)
LIST ANY SCHOLARSHIPS, ACADEMIC HONORS, AWARDS OR SPECIAL ACHIEVEMENTS
ATTORNEY
APPLICANTS
ONLY
ARE YOU LICENSED TO PRACTICE LAW IN THE STATE OF MISSOURI AND
CURRENTLY IN GOOD STANDING WITH THE MISSOURI BAR?
YES
NO
IF YES, LIST MISSOURI BAR NUMBER
IF NOT CURRENTLY LICENSED IN MO, WHEN DO YOU ANTICIPATE
LICENSURE TO PRACTICE LAW IN THE STATE OF MISSOURI?
IF LICENSED IN ANOTHER STATE, PLEASE
INDICATE STATE(S) OF LICENSURE
EMPLOYMENT HISTORY
PROVIDE EMPLOYMENT INFORMATION FOR LAST 10 YEARS, BEGINNING WITH CURRENT OR MOST
RECENT EMPLOYER. ATTACH ADDITIONAL SHEETS IF NECESSARY.
NOTE: A RESUME MAY NOT
BE SUBSTITUTED FOR THE INFORMATION REQUIRED IN THIS APPLICATION.
CURRENT OR MOST RECENT - NAME OF EMPLOYER
PHONE (include area code)
ADDRESS (number & street) CITY STATE ZIP IMMEDIATE SUPERVISOR
EMPLOYMENT DATES (MONTH & YEAR)
FROM: TO:
TITLE OF POSITION
DESCRIPTION OF DUTIES
REASON FOR SEEKING OTHER EMPLOYMENT
MAY WE CONTACT THIS EMPLOYER?
YES
NO If no, please explain:
NAME OF EMPLOYER
PHONE (include area code)
ADDRESS (number & street) CITY STATE ZIP IMMEDIATE SUPERVISOR
EMPLOYMENT DATES (MONTH & YEAR)
FROM: TO:
TITLE OF POSITION
DESCRIPTION OF DUTIES
REASON FOR CHANGE OR LEAVING
MAY WE CONTACT THIS EMPLOYER?
YES
NO If no, please explain:
2 of 4
EMPLOYMENT HISTORY (continued)
NAME OF EMPLOYER
PHONE (include area code)
ADDRESS (number & street) CITY STATE ZIP IMMEDIATE SUPERVISOR
EMPLOYMENT DATES (MONTH & YEAR)
FROM: TO:
TITLE OF POSITION
DESCRIPTION OF DUTIES
REASON FOR CHANGE OR LEAVING
MAY WE CONTACT THIS EMPLOYER?
YES NO If no, please explain:
NAME OF EMPLOYER
PHONE (include area code)
ADDRESS (number & street) CITY STATE ZIP IMMEDIATE SUPERVISOR
EMPLOYMENT DATES (MONTH & YEAR)
FROM: TO:
TITLE OF POSITION
DESCRIPTION OF DUTIES
REASON FOR CHANGE OR LEAVING
MAY WE CONTACT THIS EMPLOYER?
YES
NO If no, please explain:
MILITARY SERVICE
HAVE YOU SERVED IN THE U.S. ARMED FORCES?
YES NO
PERIOD OF ACTIVE DUTY (MONTH/YEAR)
BRANCH OF SERVICE DATE OF FINAL DISCHARGE RANK AT TIME OF DISCHARGE
DO YOU HAVE ANY EXPERIENCE FROM MILITARY SERVICE THAT WOULD BE RELEVANT TO THE POSITION(S) FOR WHICH YOU ARE APPLYING?
SKILLS
PLEASE INDICATE SKILL BY CHECKING THE APPROPRIATE BOXES:
TYPING
WORD PROCESSING COMPUTER SOFTWARE
________ W.P.M. LIST SOFTWARE:______________________________________________________________
OTHER OFFICE EQUIPMENT YOU ARE FAMILIAR WITH
LIST FOREIGN LANGUAGES THAT YOU SPEAK OR READ PROFICIENTLY
ARE THERE ANY OTHER EXPERIENCES, SKILLS, OR QUALIFICATIONS THAT YOU THINK WOULD ESPECIALLY PREPARE YOU FOR WORK WITH THIS
DEPARTMENT?
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
3 of 4
4 of 4
Applications will remain on file for 120 days in order to maintain control
of document flow. An applicant may request to reactivate an
application every 120 days, not to exceed 1 year.
THE MISSOURI STATE PUBLIC DEFENDER SYSTEM IS AN EQUAL OPPORTUNITY EMPLOYER.
APPLICANTS WILL RECEIVE CONSIDERATION FOR POSITIONS WITHOUT REGARD TO
RACE, COLOR, RELIGION, DISABILITY, AGE, SEX, SEXUAL ORIENTATION, MARITAL STATUS,
VETERAN STATUS OR ANY OTHER STATUS PROTECTED UNDER LOCAL, STATE, OR FEDERAL LAWS.
REFERENCES
DO NOT LIST RELATIVES. INCLUDE INDIVIDUALS WHO HAVE KNOWLEDGE OF YOUR BACKGROUND.
NAME
ADDRESS PHONE (include area code)
OCCUPATION RELATIONSHIP TO REFERENCE
NAME
ADDRESS PHONE (include area code)
OCCUPATION RELATIONSHIP TO REFERENCE
NAME
ADDRESS PHONE (include area code)
OCCUPATION RELATIONSHIP TO REFERENCE
APPLICANT CERTIFICATION
l I hereby authorize the Missouri State Public Defender System to make any investigations regarding my personal
history. This includes the thorough investigation of my references, work record, education, and any information
necessary in arriving at an employment decision. Pursuant to the Driver's Privacy Protection Act, I hereby authorize
MSPD to obtain my driver's record from the Missouri Motor Vehicle & Driver Licensing Division or the equivalent in any
other state in which I may have a driver's license. I further authorize my previous employers to release to the Public
Defender System any information they may have regarding my character or employment history, whether on record or
not. I hereby release the Public Defender System, my former employers and all other persons, corporations,
partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any way related to
such investigation or disclosure.
l If employed by the Public Defender, I understand that my employment would be "at will" and could be terminated at
any time by either party, with or without cause.
l State law requires all state employees to file all state income tax returns and pay all state income taxes owed. I
understand that verification of taxes owed will be conducted by the state and failure to satisfy any liability or payment
owed will result in termination of employment.
l The U.S. Military Selective Service act requires males age 18 through 26 to register with the Selective Service
Administration. I certify that I am registered with the Selective Service Administration if I am subject to this act.
l I certify that all of the statements in this application are true, complete, and correct to the best of my knowledge and
belief and are made in good faith. I understand that if I am employed, any falsification, misrepresentation, or omission
on this application shall be considered sufficient cause for dismissal.
By typing or signing my complete name below, I hereby attest to the statements above:
Name: Date:
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APPLICATION FOR EMPLOYMENT Print in black ink or (Missouri)

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Completed 26 July 2021

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