Employment Application

Job Application

1. Job Applied for Choose an open position. Career Path Equipment Operators Refuse Collection & Disposal Supervisor- *Current Employees ONLY*
2. Date Available

Personal Information

1. First Name
2. Middle Name
3. Last Name
4. Email
5. Phone
6. Alternate Phone
7. Address
8. City
9. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
10. Zip
11. How long have you lived at this address? < 1 Year 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30+ Years

Previous Address

12. Address
13. City
14. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
15. Zip
16. How long did you live at this address? < 1 Year 1 Years 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years 26 Years 27 Years 28 Years 29 Years 30+ Years

Background

1. Are you a U.S. Citizen? Please Select Yes No
2. Are you prevented from lawfully becoming employed in this country because of Visa or immigration status? Please Select Yes No
If yes, please explain.
3. Have you ever been convicted of a felony?
   For purposes of these questions, convicted includes plead guilty, plead no contest, or been given a deferred sentence of judgment. Please Select Yes No
If yes, please explain.
4. Have you interviewed with the County in the past 12 months? Please Select Yes No
If yes, which position(s)?
5. Have you ever been employed by Houston County? Please Select Yes No
Employed Start Date:
Employed End Date:
Employed Position
Reason for Leaving
6. Drivers License Please Select None Regular A B CDL

Education

High School

1. Name and Location
2. Did you Graduate? Please Select Yes No No, but received GED

College or Trade School

1. Name and Location
2. Did you Graduate? Please Select Yes No
3. Major/Subject

Graduate/College

1. Name and Location
2. Did you Graduate? Please Select Yes No
3. Major/Subject
4. Describe any specialized training, apprenticeship, skills, and/or extracurricular activities.

Employment History

List employment from the past 10 years, starting with your most recent job. Account for any time period that you were unemployed by stating the nature of your activities.

Employer 1

1. Employer Name
2. Address
3. City
4. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Zip
6. Phone
7. Job Title
8. Supervisor Name
9. Start Date
10. End Date
11. Work Performed
12. Reason For Leaving
13. Can we contact current employer? Please Select Yes No
Add Employer

Optional: Upload Resume

1. Resume
   only PDF files are allowed

References

Please list three personal references, other than prior employers or relatives, whom we can contact.

Reference 1

1. Name
2. Phone
3. How long have you known this reference?
4. Occupation

Reference 2

1. Name
2. Phone
3. How long have you known this reference?
4. Occupation

Reference 3

1. Name
2. Phone
3. How long have you known this reference?
4. Occupation

Military Service Record

1. Have you ever served in the armed forces? Please Select Yes No
Branch
Rank Discharge: List your duties in service, including special training.
Any person who may wish to claim a Veterans Preference must submit a copy of a certified form DD214 by the deadline set for the receipt of applications for the position for which the person is applying.
Upload DD214 Form
only PDF files are allowed
Attention: Applicants having military experience should also read and sign the following statement: I authorize the National Personnel Records Center, St Louis, MO or other custodian/s of my military record to release to the Houston County Personnel Board, information or photocopies form my military personnel and related medical records, or only the following informational records.
Signature Please type your full name to serve as an electronic signature.

EEO Reporting Data

The following data is requsted for Equal Employment Opportunity record keeping and reporting compliance purposes only as specified by Title VII of the Civil Rights Act of 1964 as amended. This section is voluntary and will be kept confidential.

1. Please select one. American Indian or Alaskan Native: persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.
   White, not of Hispanic Origin: persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
   Black, not of Hispanic Origin: persons having origins in any of the Black racial groups of Africa.
   Asian, or Pacific Islander: persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.
   Hispanic: persons of Mexican, Puerto Rican, Cuban, Central of South American, or other Spanish culture or origin, regardless of race.
   Other

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2. Sex Please Select Male Female Other

Special Conditions

1. You may inform us if you have a disability requiring accommodation. State any additional information you feel would be helpful to us in considering your application.
2. Are you related by blood or marriage to any official, department head, or supervisor of any Houston County department, board, bureau, committee, commission, institution, corporation, authority, or other agency? Please Select Yes No
If yes, please list their name and title of their position.

Authorization and Release

Please read carefully before signing.

I understand that all appointments are probationary for a period of six months. during which time I must demonstrate my fitness for continued employment. I also understand that all appointments offered me will be contingent upon the results of a complete character and fitness investigation. I am aware that willfully withholding information or making false statements on the application will be a basis for denial of a position prior to employment, or will be grounds for dismissal after appointment. I agree that this application and all other papers shall be confidential records of the Personnel Board subject to inspection by the appointing authority. I hereby certify that all statements are true and correct to the best of my knowledge.

A FALSE STATEMENT ON ANY PART OF YOUR APPLICATION MAY BE GROUNDS FOR NOT HIRING YOU, OR FOR TERMINATION OF YOUR EMPLOYMENT AFTER YOU BEGIN WORK.

I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability and fitness of employment with Houston County by law enforcement agencies, employers, schools, and other individuals and organizations, to personnel staffing specialists, and other authorized employees of Houston County. I certify that to the best of my knowledge and belief, all of my statements on employment applications and related employment papers are true, correct, and complete, and made in good faith. I hereby release the aforementioned persons, corporations, agencies, associations and their employees, agents and representatives from any and all liability for damages of what ever kind of nature which may at any time result to me on account of compliance with this authorization. A copy of this authorization shall be effective and valid as the original.

Your Signature

1. Signature Please type your full name to serve as an electronic signature.
2. Today's Date