City of Social Circle
An Equal Opportunity Employer and Drug Free Workplace
Public Safety Police and Fire Employment Application
Attach additional sheets if needed to completely answer every item.
1
Rev 2015-10-04
Last Name
First
Middle
Mother’s Maiden
Name
Mailing Address
Apartment/Unit #
Physical Address
Apartment/Unit #
City
State
ZIP
Home #
Work #
Email Address
Position Applied For
Date Available
Desired Annual Salary
Are you a citizen of the United States? YES NO
Have you ever worked for the City? YES NO If so, when?
AVAILABILITY
Will your schedule allow you to fulfill all of the job requirements? YES NO
Are you available to work overtime? YES NO Shifts? YES NO
Travel out of town and out-of-state overnight? YES NO
EDUCATION
High School
Address
Did you graduate? YES NO
Degree
College
Address
Did you graduate? YES NO
Degree
Other
Address
Did you graduate? YES NO
Degree
City of Social Circle
An Equal Opportunity Employer and Drug Free Workplace
Public Safety Police and Fire Em
ployment Application
Attach additional sheets if needed to completely answer every item.
2
Rev 2015-10-04
REFERENCES Please list three professional references.
Full Name Relationship
Company Phone
Address
Full Name Relationship
Company Phone
Address
Full Name Relationship
Company Phone
Address
FIRE - POLICE CERTIFICATION
Are you a Georgia Certified Peace Officer or certified in any other state? YES NO If yes, enter certificate # and attach
copy.
Are you a Georgia Certified Firefighter or certified in any other state? YES NO If yes, enter certificate # and attach copy.
MILITARY SERVICE
Branch From To
Rank at Discharge Type of Discharge
If other than honorable, explain
City of Social Circle
An Equal Opportunity Employer and Drug Free Workplace
Public Safety Police and Fire Em
ployment Application
Attach additional sheets if needed to completely answer every item.
3
Rev 2015-10-04
PAST 10 YEARS OF EMPLOYMENT HISTORY BEGINNING WITH MOST RECENT EMPLOYMENT
Company Phone
Address Supervisor
Job Title Starting Salary $ Ending Salary $
Responsibilities
From To Reason for Leaving
May we contact this supervisor for a reference? YES NO
Company Phone
Address Supervisor
Job Title Starting Salary $ Ending Salary $
Responsibilities
From To Reason for Leaving
May we contact your previous supervisor for a reference? YES NO
Company Phone
Address Supervisor
Job Title Starting Salary $ Ending Salary $
Responsibilities
From To Reason for Leaving
May we contact your previous supervisor for a reference? YES NO
City of Social Circle
An Equal Opportunity Employer and Drug Free Workplace
Public Safety Police and Fire Em
ployment Application
Attach additional sheets if needed to completely answer every item.
4
Rev 2015-10-04
RESIDENCES List below all addresses where you have lived for the past 10 years, beginning with your present address.
FROM To Rent Own
Address
City State Zip
FROM To Rent Own
Address
City State Zip
FROM To Rent Own
Address
City State Zip
FROM To Rent Own
Address
City State Zip
FROM To Rent Own
Address
City State Zip
Have you ever been evicted? Yes No If yes, please explain
City of Social Circle
An Equal Opportunity Employer and Drug Free Workplace
Public Safety Police and Fire Emp
loyment Application
Attach additional sheets if needed to completely answer every item.
5
Rev 2015-10-04
DRUG - ALCOHOL USE
Do you currently take any prescription medications not prescribed to you by a physician? Yes No If yes, please explain.
List the types of illegal drugs you have used and the date you last used them.
Have you ever been disciplined or terminated from an employer because of illegal drug use? Yes No If yes, please
explain.
Have you ever used illegal drugs or alcohol while at work or while operating an employer’s vehicle? Yes No
If yes, please explain.
CONVICTIONS
Have you ever been convicted of a crime? Yes No If yes, please explain.
Have you ever been convicted of a crime involving Domestic Violence? Yes No If yes, please explain.
EMPLOYMENT ACTIONS
Have you been terminated or forced to resign from an employer? Yes No If yes, please explain.
Have you ever been terminated or disciplined for being late to work? Yes No If yes, please explain.
If you are certified in GA or any other state, do you have any previous investigations? Yes No If yes, please explain.
If you are certified in GA or any other state, do you have any pending investigations? Yes No If yes, please explain.
WORK ISSUES
Do you object to wearing a uniform? Yes No
Do you object to wearing a firearm while off duty? Yes No
City of Social Circle
An Equal Opportunity Employer and Drug Free Workplace
Public Safety Police and Fire Emp
loyment Application
Attach additional sheets if needed to completely answer every item.
6
Rev 2015-10-04
AFFIRMATION AND SIGNATURE
I swear and affirm that my answers are true and complete to the best of my knowledge. If this application package leads to
employment, I understand that false or misleading information in my application package or interview may result in my release at
any time. I understand that the City of Social Circle (ID# 99723) is required by law to use E-Verify when making employment
decisions. I understand that E-Verify is an Internet-based system that compares information from Federal Form I-9, Employment
Eligibility Verification, to data from U.S. Department of Homeland Security and Social Security Administration records to confirm
employment eligibility. I understand that any offer of employment is contingent upon all information provided being accurate and
complete, including information submitted with Federal Form I-9 between acceptance of an offer and the first day of work.
Signature Date
PLEASE ATTACH COPIES
Military DD214 Discharge
Valid driver’s license
GED/DIPLOMA
POST certification
FF certification
Any other certifications or degrees
These will not be returned to you.
CONSENT FORMS
Authorization for Release of Personal Information
Please complete consent form in the next section.
City of Social Circle
An Equal Opportunity Employer and Drug Free Workplace
Public Safety Police and Fire Employment Application
Attach additional sheets if needed to completely answer every item.
7
Rev 2015-10-04
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I, (enter your full name here) ___________________________________________________________________________
do hereby authorize a review and full disclosure of all records concerning myself to any duly authorized officer or agent of the Social
Circle Police Department, or their designee, such as the Georgia Bureau of Investigation, whether such records are of a public,
private, or confidential nature.
The intent of this authorization is to give my consent for full and complete disclosure of all records of my driver's history, criminal
history, educational background, military personnel records, records of military service, records of financial or credit institutions
(including records of loans), records of commercial or retail credit agencies (including credit reports and/or rating), records of the
Georgia Department of Revenue, and any other financial statements and records wherever filed, as well as U.S. Veterans
Administration records, and employment and pre-employment records (including background reports, polygraph reports and
charts, efficiency ratings, complaints or grievances filed by or against me).
I understand that any information obtained by a personal history background investigation that is developed directly or indirectly, in
completely or in part, upon this release authorization will be used in determining my suitability for employment with or for the Social
Circle Police Department or appointment to a governmental position of trust. I authorize the disclosure of the aforementioned
personal information to any person(s) deemed by the Social Circle Police Department to be a participant in the determination
process of such suitability. I also certify that any person(s) who may furnish such information concerning me shall not be held
accountable for giving this information; and I do hereby release said person(s) from any and all liability, which may be incurred as a
result of furnishing such information.
A photocopy of this release form will be as valid as the original form, even though the photocopy does not contain my original
signature.
I have read and fully understand the contents of this Authorization for Release of Personal Information document.
Signature (including maiden name)
Date
Last Name
First
Middle
Mother’s Maiden Name
Street Address
City/State
Zip
Mailing Address (if different from Street Address)
City/State
Zip
Social Security Number
Date of Birth
Sex
Race
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