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Application for Employment City of Augusta HUMAN RESOURCES DEPARTMENT ROOM 601, MUNICIPAL BUILDING, AUGUSTA, GEORGIA 30911 www.co.richmond.ga.us JOB LINE# (706) 821-2305 PHONE: (706) 821-2303 FAX: (706) 821-2867 In order to be considered for a position, applications must be complete. You must PRINT, SIGN and DATE your application in INK. Position Applying For Date Name Last First MI Current Address City State Zip Code Telephone Number(s) ( ) ( ) ( ) Have you ever been employed with the City of Augusta or Richmond County before? Yes No If yes, Date Position On what date would you be available for work? If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No N/A If you are required to register with the Selective Service, can you show proof of registration? (Required of males ages 18 – 26.) Yes No N/A Are you currently employed? Yes No May we contact your present employer? Yes No Are you legally eligible to work in the U.S.? Yes No Do you have any relatives employed with us? Yes No If yes, Name Relation Dept If yes, Name Relation Dept Have you ever been convicted of, plead guilty or no contest to a misdemeanor?* Yes No If yes, please give date and explanation. Have you ever been convicted of, plead guilty or no contest to a felony?* Yes No If yes, please give date and explanation. *A misdemeanor or felony conviction will not necessarily disqualify a job candidate from being considered for a position, unless applicable by law. Education High School School Name and Address Did you graduate? Yes No If not a high school graduate, do you have a GED? Yes No Technical or Business Schools School Name and Address Number of years attended Course of study Did you graduate? Degree obtained Yes No Yes No Colleges/Universities School Name and Address Number of years attended Course of study Did you graduate? Degree obtained Yes No Yes No Yes No Yes No Yes No WE ARE AN EQUAL OPPORTUNITY EMPLOYER Augusta is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, gender, age, national origin or disability. Applications are kept on file for 90 days. ---PAGE BREAK--- Application for Employment City of Augusta References: List three personal references who are not related to you and are not previous employers. Name Address Phone Number Years Known Employment History: List most recent or current job first: (please cover last eight years, attach additional page if needed.) Name of Organization Telephone ( ) Dates Employed From mo/yr To mo/yr Number and Street City State Zip Code May we contact this employer? Yes No Official Job Title Name of Supervisor Pay (hourly rate/salary) Starting Final Describe Specific Job Reason for Leaving Name of Organization Telephone ( ) Dates Employed From mo/yr To mo/yr Number and Street City State Zip Code May we contact this employer? Yes No Official Job Title Name of Supervisor Pay (hourly rate/salary) Starting Final Describe Specific Job Reason for Leaving Name of Organization Telephone ( ) Dates Employed From mo/yr To mo/yr Number and Street City State Zip Code May we contact this employer? Yes No Official Job Title Name of Supervisor Pay (hourly rate/salary) Starting Final Describe Specific Job Reason for Leaving List any additional training, skills or equipment you are skilled in operating related to the position in which you are applying. (This may include computer applications, typing speed, a CDL license, or any other Authorization and Release My signature on this application form attests to the fact that all information included is true to the best of my knowledge. I am aware that falsification/misrepresentation on any part of this application form and attached resume or credentials may disqualify me for employment or result in immediate dismissal, regardless of when discovered. I understand that any employment pursuant to this application shall be subject to the condition that I pass the pre-employment drug screening urinalysis test and that information regarding use of drugs may be disclosed to the appropriate county representative as a part of the employment process. I further understand that a post-offer of employment physical examination is also required for certain positions, and in those cases, employment is conditional upon successfully passing the examination. All medical information will be classified as confidential. ---PAGE BREAK--- Signature of Applicant Date APPLICANT DATA SHEET COMPLETION OF THIS FORM IS VOLUNTARY INSTRUCTIONS: The Augusta government is an equal opportunity employer committed to the policies and principles of affirmative action. To help us comply with federal equal opportunity record- keeping requirements, please answer the questions on this survey. This information will assist the Human Resources Department in ensuring that our recruitment efforts are reaching all areas in the community and that all protected classes are represented in our applicant pool. This data will be used in periodic government reporting and will be kept in a confidential file separate from the Application for Employment. Failure to submit this data will not in any way effect your present or future employment. 1. Ethnic Background (Please check only one): a. Caucasian (Not of Hispanic Origin) d. Hispanic b. African American (Not of Hispanic Origin) e. Asian/Pacific Islander c. American Indian/Alaskan Native f. Other 2. Gender: a. Male b. Female 3. Birth Date: Month Day Year Age 4. Do you currently have a disability that is covered under the Americans With Disabilities Act (ADA)? Yes No 5. How did you hear about this job? (Please check all that apply) a. Local Newspaper f. Job Announcement b. State Employment Agency g. Job Line c. Minority Organization h. Internet d. Professional Publication i. Other e. Current Employee NAME DATE OF APPLICATION TITLE OR POSITION FOR WHICH YOU ARE APPLYING Applicants are considered for all positions without regard to race, color, ---PAGE BREAK--- religion, gender, national origin, age or disability.