Fillable Form 1441 APPLICATION FOR EMPLOYMENT (DESOTO COUNTY)

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Form 1441 APPLICATION FOR EMPLOYMENT (DESOTO COUNTY)

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The Form 1441 APPLICATION FOR EMPLOYMENT (DESOTO COUNTY) form is 7 pages long and contains:

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  • 80 check-boxes
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U.S.A. forms for DESOTO COUNTY

BROWSE DESOTO COUNTY (MS) FORMS

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APPLICATION FOR EMPLOYMENT
DcSoto County accepts applications for employment without regard to race, color, religion, creed,
gender, national origin, age, disability, marital or veteran status, or any other legally protected status.
Employment Opportunities available at
www.desotocountyms.gov
Email: hr@desotocountyms.gov
Fax: (662) 469-8266
Applications must be complete. Incomplete or unsigned applications are subject to disqualification.
Please Print or Type
Name:_____________________________________________________________________________
Last First Middle Initial
Address:____________________________________________________________________________
Street City Zip
Home Phone: ( _)_________________________ Cell Phone: ( )
_______________________________
Do you have a valid diver’s license? [ ] Yes [ ] No
State Issued ______________ Please provide driver’s license number, if driving is required if hired:________________________
Have you ever been employed by Desoto County? [ ] Yes [ ] No
If yes, please provide dates:_______________________________________
Are you currently employed? [ ] Yes [ ] No
May we contact your current employer? [ ] Yes [ ] No
Are you able to work? [ ] Full Time [ ] Part Time [ ] Weekends
Are you able to work overtime? [ ] Yes [ ] No
On what date would you be available to begin work? _________________
Minimum salary acceptable $______________
Have you ever been convicted of, or plead guilty or no contest to, a crime
other than a minor traffic violation? [ ] Yes [ ] No
CONVICTION WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT. EACH INSTANCE AND EXPLANATION WILL BE CONSIDERED IN RELATIONS TO THE
POSITION FOR WHICH YOU ARE APPLYING.
Position(s) Applying For Date of Application
County Administration
365 Losher Street
Hernando, MS 38632
Telephone (662) 469-8020
OR
Road Department
2373 Gwynn Road
Nesbit, MS 3865
Telephone (662) 469-8025
Fax : (662) 469-8749
Or Apply in Person
An Equal Opportunity Employer
2
Education
Computer Skills
Word [ ] [ ] [ ]
Excel [ ] [ ] [ ]
Access
[ ] [ ] [ ]
Publisher
[ ] [ ] [ ]
Power Point [ ] [ ] [ ]
Other:_______________________________________________________________
Special Training or Skill
List any special training or skills that would be of benefit in the job for which you are applying.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
High School:
Name of School___________________________ [ ] Diploma [ ] Other (specify)_______
College, University or Professional School:
Name of School ____________________________ Dates Attended_________to________
Did You Graduate? [ ] Yes [ ] No Type of Degree____________________________
Name of School ____________________________ Dates Attended________to_________
Did You Graduate? [ ] Yes [ ] No Type of Degree____________________________
Vocational Training or Other:
Location:_____________________________________________________________
Course of Study:________________________________________________________
Certification [ ] Yes [ ] No
What type of certification?_________________________________________________
Beginner Intermediate Advanced
3
Employment History
Employer:______________________________________________________________________
Contact Name/Position:_____________________________ Telephone: ( )______________________
Address:________________________________________________________________________
Job Title:____________________________ Hourly Rate/ Salary: Start_________ Finish____________
Dates of Employment:___________ to _______________
Work performed: __________________________________________________________________
______________________________________________________________________________
Reason for leaving:_________________________________________________________________
May we contact: [ ] Yes [ ] No
Employer:______________________________________________________________________
Contact Name/Position:_____________________________ Telephone: ( )______________________
Address:________________________________________________________________________
Job Title:____________________________ Hourly Rate/ Salary: Start_________ Finish____________
Dates of Employment:___________ to _______________
Work performed: __________________________________________________________________
______________________________________________________________________________
Reason for leaving:_________________________________________________________________
May we contact: [ ] Yes [ ] No
Employer:______________________________________________________________________
Contact Name/Position:_____________________________ Telephone: ( )______________________
Address:________________________________________________________________________
Job Title:____________________________ Hourly Rate/ Salary: Start_________ Finish____________
Dates of Employment:___________ to _______________
Work performed: __________________________________________________________________
______________________________________________________________________________
Reason for leaving:_________________________________________________________________
May we contact: [ ] Yes [ ] No
Comments: Include explanation of any gaps in employment below.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4
Personal/Professional References:
Please give at least three (3) references who do not include family members or former
employers.
Name:___________________________________________________________
Title:____________________________________________________________
Relationship to you:__________________________________________________
Telephone: ( )_____________________ Years Known:_____________________
Name:___________________________________________________________
Title:____________________________________________________________
Relationship to you:__________________________________________________
Telephone: ( )_____________________ Years Known:_____________________
Name:___________________________________________________________
Title:____________________________________________________________
Relationship to you:__________________________________________________
Telephone: ( )_____________________ Years Known:_____________________
Name:___________________________________________________________
Title:____________________________________________________________
Relationship to you:__________________________________________________
Telephone: ( )_____________________ Years Known:_____________________
Name:___________________________________________________________
Title:____________________________________________________________
Relationship to you:__________________________________________________
Telephone: ( )_____________________ Years Known:_____________________
5
Applicant’s Statement:
I certify that all the information submitted are true, correct and made in good faith.
I am aware that any omissions, falsifications, misstatements or misrepresentations above may
disqualify me for employment consideration and if I am hired , may be grounds for termination at a
later date. I understand that any information I may give in this application or in the continuing
application process may be subject to verification and investigation. I consent to the release of
information about my ability and employment history from employers, schools, law enforcement
agencies, and other individuals and organizations to our HR staff and other authorized representatives
of the DeSoto County Board of Supervisors for employment purposes.
The application for employment shall be considered active for a period of time not to exceed ninety
(90) days. At the expiration of said ninety (90) day period, the application will be void, and an
applicant must file a new application as required under Section 2.100 of the DeSoto County Personnel
Manual to be considered for employment in a position with DeSoto County.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any
employment relationship with this organization is of an “at will” nature, which means that the
Employee may resign at any time and the Employer may discharge Employee at any time with or
without cause. It is further understand that this “at will” employment relationship may not be
changed by any written document or by conduct unless such change is specifically acknowledged in
writing by an authorized executive of this organization.
I also understand by signing this document I hereby agree to a drug screen test and background check
and understand, also, that I am required to abide by all policies and regulations of the employer.
Signature of Applicant _____________________________________
Date________________________________________
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6
REQUIRED FOR ROAD DEPARTMENT EMPLOYMENT ONLY
If you are applying for a DeSoto County Road Department position you must complete this form and return it
along with the application to the Road Department located at:
2373 Gwynn Road
Nesbit, MS 38651
(622) 469-8025
I understand that providing false information could result in non-acceptance of my resume and/or termination of
my employment.
Please check all that apply.
SUPERVISOR
____ Foreman ____________ ________________________________________________
____Crew Leader ____________ ________________________________________________
____Manager ____________ ________________________________________________
OFFICE/CLERICAL
____Bookkeeping ____________ ________________________________________________
____Receptionist ____________ ________________________________________________
____Secretary ____________ ________________________________________________
TECHNICAL
____Inspector ____________ ________________________________________________
____Mechanic ____________ ________________________________________________
____Carpenter ____________ ________________________________________________
____Concrete Finisher ____________ ________________________________________________
____Welder ____________ ________________________________________________
EQUIPMENT
____Trackhoe ____________ ________________________________________________
____Dozer ____________ ________________________________________________
____Motor Grader ____________ ________________________________________________
____Tractor with Dirt Pan ____________ ________________________________________________
____Track Loader ____________ ________________________________________________
____Four Wheel Driver Loader ____________ ________________________________________________
____Backhoe/Loader ____________ ________________________________________________
____Asphalt Spreader ____________ ________________________________________________
____Chip Spreader ____________ ________________________________________________
____Widening Machine ____________ ________________________________________________
____Asphalt Distributor ____________ ________________________________________________
____Asphalt Roller ____________ ________________________________________________
____Sheep’s Foot Roller ____________ ________________________________________________
____Power Broom ____________ ________________________________________________
____Tractor Truck with Lowboy ____________ ________________________________________________
____Tractor Truck with Dump Trailer ____________ ________________________________________________
____Tandem Dump Truck ____________ ________________________________________________
____Single Axel Dump Truck ____________ ________________________________________________
____Roadside Sprayer Truck ____________ ________________________________________________
____Lube/Service Truck ____________ ________________________________________________
____Tractor with Boom Mower ____________ ________________________________________________
____Tractor with Roadside Mower ____________ ________________________________________________
____Chain Saw ____________ ________________________________________________
____Concrete Saw ____________ ________________________________________________
____Patch Roller
____________ ______________________________________________________
OTHER
____________________________________________________________________________________________________________________
Years Employer Name
FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION
DISCLOSURE
In considering you as an applicant for employment or as a current employee, we may choose to secure and use
information contained in either a consumer report or investigative consumer report about you obtained from a consumer
reporting agency when: (1) considering your application for employment (2) making a decision whether to offer you
employment, (3) deciding whether to continue your employment or (4) making other employment-related decisions
directly affecting you.
For explanation purposes, a "consumer reporting agency" is a person or business that, on a cooperative nonprofit basis, or
for monetary fees or dues, regularly assembles or evaluates consumer credit information or other information on
consumers for a person who has a legitimate business need for the information or intends to use the information for
employment purposes.
A "consumer report" means any written, oral or other communication of any information by a consumer reporting
agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal
characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose
of serving as a factor in establishing your eligibility for employment purposes.
An "investigative consumer report" means a consumer report or portion thereof in which information on your
character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with
your neighbors, friends, or associates reported on or with others with whom you are acquainted or who may have
knowledge concerning any such items of information.
In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and
scope of the investigation requested as well as a written summary of your rights under the Fair Credit Reporting Act.
AUTHORIZATION
By your signature below, you hereby authorize us to obtain a consumer report from a consumer reporting agency, or other
permissible source and/or an investigative report about you and to consider this information when making decisions
regarding my employment. I understand that I have rights under the Fair Credit Reporting Act, including the rights
discussed above in order to consider you for employment. If hired, this authorization shall remain on file and shall serve
as an ongoing authorization for us to procure consumer reports at any time during the employment period.
____________________________________________________________ ____________________________
(Signature) (Date)
____________________________________________________________
(Printed)
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Form 1441 APPLICATION FOR EMPLOYMENT (DESOTO COUNTY)

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Completed 19 July 2020

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