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JEFFERSON COUNTY COMMISSIONERS P. O. Box 658, Louisville, GA 30434 Employment Application Jefferson County is a Drug Free workplace APPLICANT INFORMATION Last Name First M.I. Date Mailing Address Apartment/Unit # City State ZIP Phone E-mail Address Date Available Referred By: Desired Salary Position Applied for Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO Have you ever worked for the county? YES NO If so, when? Have you ever been convicted of a felony? YES NO If yes, explain EDUCATION High School Address From To Did you graduate? YES NO Degree College Address From To Did you graduate? YES NO Degree Other Address From To Did you graduate? YES NO Degree REFERENCES Please list three professional references. Full Name Relationship Company Phone ( ) Address Full Name Relationship Company Phone ( ) Address Full Name Relationship Company Phone ( ) Address ---PAGE BREAK--- PREVIOUS EMPLOYMENT 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 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 MILITARY SERVICE Branch From To Rank at Discharge Type of Discharge If other than honorable, explain DISCLAIMER AND SIGNATURE I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Signature Date *Jefferson County is an Equal Opportunity Employer (EOE). Qualified applicants are considered for employment without regard to age, race, color, religion, sex, national origin, sexual orientation, disability, or veteran status. ---PAGE BREAK--- Jefferson County Commissioners’ Personnel Policy Page 80 Appendix C JEFFERSON COUNTY COMMISSIONERS MOTOR VEHICLE REPORT (MVR) CONSENT FORM I hereby authorize and fully understand that the Jefferson County Commissioners’ Personnel Department will access my Driver's License History (MVR) quarterly. Full Name (Printed) Address City State Zip Code Sex Date of Birth Driver's License Number Signature Authorization Date ---PAGE BREAK---