Employ App
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City of Hinesville 115 East M. L. King Jr. Drive Hinesville, GA 31313-3699 Phone: (912) 876-3564 Fax: (912) 369-2658 APPLICATION FOR EMPLOYMENT The City of Hinesville is an Equal Opportunity Employer. All applicants shall be assured of fair and equitable treatment in all terms and conditions of employment, including hiring, training, promotion, and disciplinary action, without regard to political affiliation, race, color, national origin, sex, sexual orientation, age, marital status, disability, military status, or religious creed and with proper regard for their privacy and constitutional rights as citizens. Please read the entire application and complete by printing in ink. This application must be accurately completed in its entirety and is subject to verification before any offer of employment may be considered. It is the applicant’s responsibility to notify the Human Resources Department of any changes to the information provided in this application. PERSONAL INFORMATION Last Name Social Security Number
First Name
Middle Initial
Home Phone
Alternate Phone
(
(
)
)
Street Address City
State
Do you posses a valid Georgia Driver’s License? ( ) Yes ( ) No
Are you at least 18 years of age? ( ) Yes ( ) No
Are you a citizen of the U.S. or are you otherwise authorized to work in this country? ( ) Yes ( ) No Wage/Salary Expected:
Position applied For
Has the City previously employed you? (
) Yes (
Zip Code
Date available for work: ) No
If so, please list:
Dates of employment: _________________________ Department ________________________
Can you perform the essential functions of the position for which you are applying? ( ) Yes ( ) No If not, what accommodations are required? If you have any question as to what functions are applicable to the position for which you are applying, please ask for a job description. _______________________________________________________________________________ _______________________________________________________________________________ Have you ever been convicted of a crime or any other offense, or do you have any charges pending against you? ( ) Yes ( ) No If yes, please explain: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ A CRIMINAL RECORD WILL NOT NECESSARILY EXCLUDE YOU FROM EMPLOYMENT BUT WILL BE CONSIDERED CONSISTENT WITH ANY APPLICABLE STATE OR FEDERAL LAW. FACTORS SUCH AS AGE AT THE TIME OF THE OFFENSE, REHABILITATION EFFORTS, RECENCY AND SERIOUSNESS OF THE CRIME WILL BE TAKEN INTO ACCOUNT. THE RELATIONSHIP BETWEEN THE OFFENSE AND THE JOB APPLIED FOR WILL ALSO BE WEIGHED.
EDUCATIONAL BACKGROUND Name of School/Institution, City and State Diploma/Degree (Please include High School, Technical School, Course of Study Colleges and Universities attended)
Did you graduate?
OTHER RELEVANT COURSES OR MILITARY TRAINING Course Title Length of Course Certificate Received
OFFICE AUTOMATION SKILLS Typing (wpm) _____
Word Processing ______
Presentation Graphics ______
Spreadsheet _____
Database Management _____
E-Mail ______
Other Applications ______
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. May we contact your present employer? ( ) Yes Employer
( ) No From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. Employer
From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. Employer
From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. Employer
From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. Employer
From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
REFERENCES List four professional references who are not related to you and who would have knowledge of your qualifications for the position in which you are applying. Reference 1 Name:
__________________________________________________________________
Address:
__________________________________________________________________
Occupation:
__________________________________________________________________
Phone Number:
____________________________________________________________
Reference 2 Name:
__________________________________________________________________
Address:
__________________________________________________________________
Occupation:
__________________________________________________________________
Phone Number:
____________________________________________________________
Reference 3 Name:
__________________________________________________________________
Address:
__________________________________________________________________
Occupation:
__________________________________________________________________
Phone Number:
____________________________________________________________
Reference 4 Name:
__________________________________________________________________
Address:
__________________________________________________________________
Occupation:
__________________________________________________________________
Phone Number:
____________________________________________________________
ADDITIONAL SPACE Please enter information in this space for any items on this form requiring further explanation or to list other special skills, additional experience, periods of time not worked or certifications relevant to the position. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I understand and acknowledge that applicants nearing final consideration for employment will be required to submit to a physical examination, including a drug/alcohol test. Additionally, I hereby authorize the release of the results of such an examination and others to the City of Hinesville’s Human Resources personnel and such person or entity they designate with a need to know, or as required by law, for their use in evaluating my suitability of employment. Further, I release the examining facility and the City of Hinesville from any damage that may result from the release of such information. Permission is granted to the City of Hinesville to conduct an investigation and to solicit information as to my educational and employment history, character and general reputation. I certify that I have answered the above questions truthfully and have not withheld any information relative to my application. I understand that any falsification, misrepresentation, or omission, as well as any misleading statements will constitute grounds for not being considered for appointment, or if appointed, for discharge. I acknowledge reading and understanding the foregoing statements. ____________________________________________ SIGNATURE Reset Form
________________________ DATE
Print Form
APPLICANT DATA RECORD The City of Hinesville is an equal opportunity employer. Our objective is to recruit, hire, train, and promote the most qualified applicants without regard to political affiliation, race, color, national origin, sex, sexual orientation, age, marital status, disability, military status, or religious creed and with proper regard for their privacy and constitutional rights as citizens. To help us comply with government record keeping, reporting and other legal requirements, please fill out the applicant data record. This data is for periodic government reporting and will be kept in a confidential, Affirmative Action file, separate from the application for employment. We appreciate your cooperation. Date _________________ Position Applied for ______________________________________________________ Name __________________________________________________________________ SEX Male Female ■
RACE Asian American Indian Black Hispanic White Other HOW DID YOU HEAR OF THIS POSITION? City’s Website Department of Labor Employee Friend Newspaper Walk In Other
First Name
Middle Initial
Home Phone
Alternate Phone
(
(
)
)
Street Address City
State
Do you posses a valid Georgia Driver’s License? ( ) Yes ( ) No
Are you at least 18 years of age? ( ) Yes ( ) No
Are you a citizen of the U.S. or are you otherwise authorized to work in this country? ( ) Yes ( ) No Wage/Salary Expected:
Position applied For
Has the City previously employed you? (
) Yes (
Zip Code
Date available for work: ) No
If so, please list:
Dates of employment: _________________________ Department ________________________
Can you perform the essential functions of the position for which you are applying? ( ) Yes ( ) No If not, what accommodations are required? If you have any question as to what functions are applicable to the position for which you are applying, please ask for a job description. _______________________________________________________________________________ _______________________________________________________________________________ Have you ever been convicted of a crime or any other offense, or do you have any charges pending against you? ( ) Yes ( ) No If yes, please explain: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ A CRIMINAL RECORD WILL NOT NECESSARILY EXCLUDE YOU FROM EMPLOYMENT BUT WILL BE CONSIDERED CONSISTENT WITH ANY APPLICABLE STATE OR FEDERAL LAW. FACTORS SUCH AS AGE AT THE TIME OF THE OFFENSE, REHABILITATION EFFORTS, RECENCY AND SERIOUSNESS OF THE CRIME WILL BE TAKEN INTO ACCOUNT. THE RELATIONSHIP BETWEEN THE OFFENSE AND THE JOB APPLIED FOR WILL ALSO BE WEIGHED.
EDUCATIONAL BACKGROUND Name of School/Institution, City and State Diploma/Degree (Please include High School, Technical School, Course of Study Colleges and Universities attended)
Did you graduate?
OTHER RELEVANT COURSES OR MILITARY TRAINING Course Title Length of Course Certificate Received
OFFICE AUTOMATION SKILLS Typing (wpm) _____
Word Processing ______
Presentation Graphics ______
Spreadsheet _____
Database Management _____
E-Mail ______
Other Applications ______
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. May we contact your present employer? ( ) Yes Employer
( ) No From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. Employer
From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. Employer
From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. Employer
From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
EMPLOYMENT HISTORY Please provide the following information about your current and past employer(s). Start with the most recent employer. Experience obtained over ten years ago that is relevant to the position you are applying must be included in your work history summary. Attach additional sheet(s) if necessary. You may include a resume with this application, but all information on the application must be completed. DO NOT STATE “SEE RESUME”. Use the space provided on the last page to account for any periods of unemployment of one month or more. Employer
From (Month/Year)
To (Month/Year)
Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving: ____________________________________________________________ Employer From (Month/Year) To (Month/Year) Address Supervisor
Title
Telephone Number, Ext.
Starting Position
Starting Base Pay
Last Position
Final Base Pay
Description of duties: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Reason for leaving:_____________________________________________________________
REFERENCES List four professional references who are not related to you and who would have knowledge of your qualifications for the position in which you are applying. Reference 1 Name:
__________________________________________________________________
Address:
__________________________________________________________________
Occupation:
__________________________________________________________________
Phone Number:
____________________________________________________________
Reference 2 Name:
__________________________________________________________________
Address:
__________________________________________________________________
Occupation:
__________________________________________________________________
Phone Number:
____________________________________________________________
Reference 3 Name:
__________________________________________________________________
Address:
__________________________________________________________________
Occupation:
__________________________________________________________________
Phone Number:
____________________________________________________________
Reference 4 Name:
__________________________________________________________________
Address:
__________________________________________________________________
Occupation:
__________________________________________________________________
Phone Number:
____________________________________________________________
ADDITIONAL SPACE Please enter information in this space for any items on this form requiring further explanation or to list other special skills, additional experience, periods of time not worked or certifications relevant to the position. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I understand and acknowledge that applicants nearing final consideration for employment will be required to submit to a physical examination, including a drug/alcohol test. Additionally, I hereby authorize the release of the results of such an examination and others to the City of Hinesville’s Human Resources personnel and such person or entity they designate with a need to know, or as required by law, for their use in evaluating my suitability of employment. Further, I release the examining facility and the City of Hinesville from any damage that may result from the release of such information. Permission is granted to the City of Hinesville to conduct an investigation and to solicit information as to my educational and employment history, character and general reputation. I certify that I have answered the above questions truthfully and have not withheld any information relative to my application. I understand that any falsification, misrepresentation, or omission, as well as any misleading statements will constitute grounds for not being considered for appointment, or if appointed, for discharge. I acknowledge reading and understanding the foregoing statements. ____________________________________________ SIGNATURE Reset Form
________________________ DATE
Print Form
APPLICANT DATA RECORD The City of Hinesville is an equal opportunity employer. Our objective is to recruit, hire, train, and promote the most qualified applicants without regard to political affiliation, race, color, national origin, sex, sexual orientation, age, marital status, disability, military status, or religious creed and with proper regard for their privacy and constitutional rights as citizens. To help us comply with government record keeping, reporting and other legal requirements, please fill out the applicant data record. This data is for periodic government reporting and will be kept in a confidential, Affirmative Action file, separate from the application for employment. We appreciate your cooperation. Date _________________ Position Applied for ______________________________________________________ Name __________________________________________________________________ SEX Male Female ■
RACE Asian American Indian Black Hispanic White Other HOW DID YOU HEAR OF THIS POSITION? City’s Website Department of Labor Employee Friend Newspaper Walk In Other
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