Fillable APPLICATION FOR EMPLOYMENT (Meriwether County Board of Commissioners)

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APPLICATION FOR EMPLOYMENT (Meriwether County Board of Commissioners)

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BROWSE MERIWETHER COUNTY BOARD OF COMMISSIONERS (GA) FORMS

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Date Submitted
(Office use only)
APPLICATION FOR EMPLOYMENT
MERIWETHER COUNTY GOVERNMENT
(Please Print or Type)
Applicants are considered for all positions without regard to race, religion, sex, national origin, age, marital status,
or the presence of a non-job related medical illness or disability
Date of Application
Position(s) Applying For
NAME
Last
First
Middle
ADDRESS
Number
Apt / Lot#
City
State
Zip
TELEPHONE
Main
Alternate
EMAIL
Email Address
Have you filed an application with Meriwether County
before?
☐
Yes
☐
No
If yes give
date:
Do you currently have any relatives working for
Meriwether County Government?
☐
Yes
☐
No
If yes please list below.
Name:
Relation:
Have you ever been employed with Meriwether County
before?
☐
Yes
☐
No
If yes give
date you left:
Are you currently employed?
☐
Yes
☐
No
May we contact your present employer?
☐
Yes
☐
No
Are you prevented from lawfully being employed in the country due to Visa or Immigration status?
☐
Yes
☐
No
Are you available for nights, weekends and on call if required?
☐
Yes
☐
No
Are you available to work:
☐
Full-Time
☐
Part-Time
☐
Seasonal
☐
Temporary
Are you on a layoff subject to recall?
☐
Yes
☐
No
Are you 18 years or older?
☐
Yes
☐
No
Some work requires out of town training, can you travel if required?
☐
Yes
☐
No
If offered employment, on what date would you be available to report for work?
Date:
Do you have a valid Georgia driver’s license?
☐
Yes
☐
No
Do you have a valid commercial driver’s license?
☐
Yes
☐
No
Have you read the job description for which you are applying?
☐
Yes
☐
No
After reading the job description, are you able to perform the essential functions of this job with or without
reasonable accommodations? ☐ Yes ☐ No
Clear Form
PLEASE SEE INSTRUCTIONS ON HOW TO SUBMIT AT THE BOTTOM OF THE
LAST PAGE OF THIS FORM.
EMPLOYMENT HISTORY – Please start with your current or most recent employer
EMPLOYER 1
Employer
Dates Employed
Telephone
From To
Address
Describe Work Duties Performed
Job Title
Hourly Rate / Salary
Starting Final
Supervisor
Reason for Leaving
EMPLOYER 2
Employer
Dates Employed
Telephone
From To
Address
Describe Work Duties Performed
Job Title
Hourly Rate / Salary
Starting Final
Supervisor
Reason for Leaving
EMPLOYER 3
Employer
Dates Employed
Telephone
From To
Address
Describe Work Duties Performed
Job Title
Hourly Rate / Salary
Starting Final
Supervisor
Reason for Leaving
EMPLOYER 4
Employer
Dates Employed
Telephone
From To
Address
Describe Work Duties Performed
Job Title
Hourly Rate / Salary
Starting Final
Supervisor
Reason for Leaving
SPECIAL SKILLS, CERTIFICATIONS,QUALIFICATIONS,SPECIALIZED TRAINING AND APPRENTICESHIPS
Please summarize any special skills, certifications, qualifications, special training or experience that you feel would be
useful in helping us consider you for the position you are applying for.
MILITARY EXPERIENCE
Were you in the U.S. Armed Forces? ☐
Yes
☐
No
If yes, which branch?
Dates of duty:
From:
To:
Rank at separation:
Type of Separation: ☐
Honorable
☐
Dishonorable
☐
Other
Please briefly describe your duties:
PLEASE LIST ANY HONORS RECEIVED
EMERGENCY CONTACT – Please list information about the person you would like contacted in case of emergency
Emergency Contact
Name:
Address:
City:
State
Zip
Best Telephone Number:
Alternate Phone Number:
Relationship to you:
EDUCATION
HIG
H SCHOOL
Name of High School:
City:
State:
Zip:
Highest Grade Completed:
☐
9
☐
10
☐
11
☐
12
Did you graduate or achieve GED?
☐
Yes
☐
No
Special Honors Received:
COLLE
GE
Name of Institution:
City:
State:
Zip:
Highest Level Completed:
☐
1
☐
2
☐
3
☐
4
Did you graduate?
☐
Yes
☐
No
Diploma or Certificate:
☐
Diploma
☐
Certificate
Subject or Major:
UND
ERGRADUATE / TECHNICAL
Name of Institution:
City:
State:
Zip:
Highest Level Completed:
☐
1
☐
2
☐
3
☐
4
Did you graduate?
☐
Yes
☐
No
Diploma or Certificate:
☐
Diploma
☐
Certificate
Subject or Major:
OTHE
R
Name of Institution:
City:
State:
Zip:
Highest Level Completed:
☐
1
☐
2
☐
3
☐
4
Did you graduate?
☐
Yes
☐
No
Diploma or Certificate:
☐
Diploma
☐
Certificate
Subject or Major:
OTHE
R
Name of Institution:
City:
State:
Zip:
Highest Level Completed:
☐
1
☐
2
☐
3
☐
4
Did you graduate?
☐
Yes
☐
No
Diploma or Certificate:
☐
Diploma
☐
Certificate
Subject or Major:
PERSONAL REFERENCES
Please provide information on three character references who are not related to you and are not previous employers.
Person
al Reference 1
Name:
Address:
City:
State
Zip
Best Telephone Number:
Years Known?
Occupation:
How do you know this person
Person
al Reference 2
Name:
Address:
City:
State
Zip
Best Telephone Number:
Years Known?
Occupation:
How do you know this person
Person
al Reference 3
Name:
Address:
City:
State
Zip
Best Telephone Number:
Years Known?
Occupation:
How do you know this person
PROFESSIONAL REFERENCE
Please provide information on one professional reference who is not related to you, that you have worked with or for
in the past.
Profes
sional Reference
Name:
Address:
City:
State
Zip
Best Telephone Number:
Where did you work with or for this person?
Occupation:
How do you know this person?
Authorization to Release Information / Conditions of Employment I have made application for employment with
Meriwether County Government. I authorize any persons or organizations to give Meriwether County Government
any and all information concerning my previous employment, education, or any other information they might have,
personal or otherwise with regard to any of the subjects covered by this application. I hereby release all such parties
from all liability for any damage whatsoever for issuing same. Furthermore, if I am employed by Meriwether County
Government, I agree to conform to the policies, rules, orders and regulations of the government set forth in the
Meriwether County Government Personnel Policy and Ordinances; and acknowledge that these policies, rules, and
regulations may be changed, interpreted, withdrawn, or added to by the Meriwether County Board of Commissioners
at any time, at the Boards sole discretion. I further acknowledge that if I become employed with Meriwether County
Government, my employment will be at-will and may be terminated with or without cause at any time by me or by
Meriwether County until such time that I am no longer on my initial trial period, and become a regular status
employee.
Alcohol and Controlled Substance Testing As a condition of employment with Meriwether County Government, I
acknowledge I will be required to submit to and successfully pass an alcohol and controlled substance test prior to
employment. Should I become an employee with Meriwether County Government, I understand that my position
requires random controlled substance testing. I understand, as a condition of my employment, I must abide by all
policies regarding the effects of drug use and the unlawful possession of controlled substances. I understand I will be
expected to report for work without the effects of illegal drugs and alcohol in my system. I understand that I must
report any conviction under a criminal drug statue for such violations. A report of the conviction must be made
within five (5) days after the conviction.
Applicants Certification and Agreement I certify that the facts set forth in this application for employment are true
and complete to the best of my knowledge. I am aware that the falsification of this application or the omission of
complete information will result in disqualification, or upon discovery, termination of my employment. Meriwether
County Government is hereby authorized to make any investigation of my prior educational and work history. I agree
that all records generated for purposes of employment are property of and shall remain the sole and exclusive
property of Meriwether County Government and may be subject to disclosure under the Georgia Open Records Act. I
acknowledge by signing this form to the conditions of employment, release of information, and consent to alcohol
and controlled substance testing requirements.
Authorization of Criminal & Drivers History Release I hereby authorize Meriwether County Government or its
designee to receive any Criminal History Record and Drivers History information pertaining to me which may be in the
files of any state or local criminal justice agency, state drivers agency and files contained in FBI, NCIC, and GCIC
databases and furthermore give consent to Meriwether County Government to perform periodic criminal and driver
history background checks for the duration of my employment
Applicants Signature
Date
I
understand that by typing my signature above, it has the same legal
si
gnifi
cance i
n thi
s case as my handwritten signature
Ver 1.2-02.26.19
INSTRUCTIONS TO APPLICANT: After filling out this application in it's entirety, download and save to your computer and
email as an attachment to humanresources@meriwethercountyga.gov or print the completed application and hand deliver or
mail to the Board of Commissioners Office attn: human resources located at 17234 Roosevelt Hwy Bldg B Greenville, GA
30222. Please DO NOT include copies of Social Security card or drivers license.
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APPLICATION FOR EMPLOYMENT (Meriwether County Board of Commissioners)

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Completed 18 July 2020

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