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Application for Employment Morgan County Commissioners P.O. Box 168 Madison Ga., 30650 If yes, please explain Drivers license number (if job related) State Equal access to programs, services, and employment is available to all persons. Those applicants requiring accommoda- tion to the application and/or interview process should contact a representative of the Personnel Department Please print Position(s) applied for Date of application / / . Referral Source Advertisement Employee Relative Government Employment Agency Walk-in Other (Name Source if Applicable) Private Employment Agency Name (last, First, Middle) Address Telephone( ) Social Security Number - - . Best time to call you at home is. : am/pm Best time to call you at work is. : am/pm May we contact you at work? Yes No Work Telephone ( ) . If you are under 18, can you provide a work permit? Yes No. Have you filed an application here before? Yes No If yes, provide date / / . Have you ever been employed here before? Yes No If yes, provide dates……...From / / To / / . Are you legally eligible for employment in this country? Yes No (Proof of U.S. Citizenship or immigration status will be required upon employment) Date available for work. Type of employment desired. Full- Time Part-Time Temporary Seasonal Educational Co-op Are you on Lay-Off and subject to recall? Yes No Will you relocate if job requires it? Yes No Will you travel if job requires it? Yes No Are you able to meet the attendance requirements of the position? Yes No Will you work over time if required? Yes No Have you ever been bonded? Yes No Have you been convicted of a felony in the past seven years? Yes No (Such a conviction may be relevant if job required, but does not bar you from employment) Morgan County is an Equal Opportunity Employer ---PAGE BREAK--- Employment History List your last four employers, assignments, or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments section. Employer Dates Employed Address From To Telephone ( ) Starting Hourly Rate/ Salary Job Title $ per Immediate Supervisor and Title $ per Reason for Leaving Final Hourly Rate/ Salary $ per May we contact for reference? Yes No $ per Summarize the nature of the work preformed and job responsibilities. Employer Dates Employed Summarize the nature of the work preformed and job responsibilities. Address From To Telephone ( ) Starting Hourly Rate/ Salary Job Title $ per Immediate Supervisor and Title $ per Reason for Leaving Final Hourly Rate/ Salary $ per May we contact for reference? Yes No $ per Employer Dates Employed Summarize the nature of the work preformed and job responsibilities. Address From To Telephone ( ) Starting Hourly Rate/ Salary Job Title $ per Immediate Supervisor and Title $ per Reason for Leaving Final Hourly Rate/ Salary $ per May we contact for reference? Yes No $ per Employer Dates Employed Summarize the nature of the work preformed and job responsibilities. Address From To Telephone ( ) Starting Hourly Rate/ Salary Job Title $ per Immediate Supervisor and Title $ per Reason for Leaving Final Hourly Rate/ Salary $ per May we contact for reference? Yes No $ per ---PAGE BREAK--- Educational Background A. School B. Years completed C. Degree/Diploma D. GPA/Class Rank E. Major F. Minor A. List the last three schools attended, starting with the most recent. B. List the number of years completed. C. Indicate degree or diploma earned, if any Grade Point Average or Class Rank. E. & F. Major and minor fields of study (if applicable). Language Speak Some Speak Fluently Read Write List any Foreign Language(s) you know and check the boxes that describe your skill level. References Name Telephone Years Known List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applica- ble list the school or personal references who are not related to you. Organization Offices Held List Professional, Trade, Business, or Civic associations and any other offices held. (Exclude any memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.) List any accomplishments, publications, awards. (Exclude any memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected List any additional information you would like us to ---PAGE BREAK--- Georgia Bureau of Investigation Georgia Crime Information Center Consent Form I hereby authorize Morgan County Board of Commissioners to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. Full Name (Print) Address Sex Race Date of Birth Social Security Number Signature Date I, give consent to the above named to perform periodic criminal history background checks for the duration of my em- ployment with the Morgan County Board of Commissioners. SPECIAL CONDITIONS O.C.G.A. 35-3-35 IF AN ADVERSE EMPLOYMENT OR LICENSING DECISION IS MADE AGAINST THE PERSON WHOSE RECORD WAS OBTAINED UNDER THIS LAW, THE PERSON SHALL BE IN- FORMED: 1. THAT A RECORD WAS OBTAINED, 2. THE SPECIFIC CONTENTS OF THE RECORDS, AND, THE EFFECT THE RECORD HAD UPON THE DECISION. FAILURE TO PROVIDE THIS INFORMATION TO THE PERSON SUBJECT TO THE ADVERSE DECI- SION SHALL BE A MISDEMEANOR. G.C.I.C. REVISED (11/05) ---PAGE BREAK--- ATTENTION When submitting your application, you also must furnish us with a copy of your valid driver’s license and Social Security Card. If you are applying for employment with the Roads and Bridges Department OR a depart- ment where you will be operating a County vehi- cle you must provide us with a certified seven year Motor Vehicle Report (MVR). This can be obtained at a cost of $7.00 from any Georgia Department of Driver Services offices which are open Tuesday through Saturday 9:00-5:00. Be- low are some locations: Covington: 8134 Geiger Street Athens: 1505 US 29 North Conyers: 2206 Eastview Parkway Milledgeville: 200 Carl Vinson Road ---PAGE BREAK--- It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer’s services if I have been employed. I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnish- ing such information. The employer is an Equal Opportunity Employer. The employer does not discriminate in em- ployment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on basis prohibited by local, state, or federal law. This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. I understand that just as I am free to resign at any time, the employer reserves the right to ter- minate my employment at any time with or without cause and without prior notice. I under- stand that no representative of the employer has the authority to make any assurances on the contrary. I understand it is the company’s policy not to refuse to hire a qualified individual with a dis- ability because of this person’s need for accommodation that would be required by the ADA. Morgan County, Georgia maintains a Drug Free Workplace Policy and applicants may be sub- ject to drug and alcohol testing. With your consent Morgan County may conduct a criminal history background check on you. Are you related to any current Morgan County Employee? Yes No If so, what is their name and what is their relation to Signature of Date