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We consider applicants for all positions without regard to race, color, sex, religion, national origin, age, marital or veteran status, the presence of a disability or any other legally protected status. POSITION OR JOB TITLE APPLIED FOR: APPLICATION FOR EMPLOYMENT Personal Data Last Name First (given) Middle Address Street Apt. # City State Zip Telephone: ( ) ( ) Business Residence Times Available at Telephone Or Cell Phone Number: ( ) e-mail address: WILL YOU ACCEPT: Temporary Work? Part-Time Work? Shift Work? Weekend/Holiday? Are you over 18 years old? Are you eligible to work in the United States either because you are a U.S. Citizen or have U.S. government permission to do so? No Yes NOTE: If offered employment you will be required to provide documentation to verify employment eligibility. Failure to provide the requested documentation may result in a determination that the applicant is ineligible for employment in the United States. Have you ever worked for us before? No Yes If yes, when and where? Are you able to perform the job duties listed for the position you are applying for without an accommodation No Yes If an accommodation is needed, how would you perform the job duties, and with what accommodation No Yes If this position requires a valid Georgia Driver's License, do you have a valid driver's license? License Class: State: Have you had any traffic violations in the past 3 years? No Yes Please indicate type of offense and dates Have you ever been convicted of an offense against the law or are you now under charges for any offense against the law? (Omit non-moving traffic violations and any offense which was finally adjudicated in a Juvenile Court or under a Youth Offender Law). No Yes If "Yes" give complete details: (Date, Place, Charges, Disposition) NOTE: A conviction will not necessarily bar you from employment. Each conviction will be judged on its own merits with respect to time, circumstances and seriousness. "We are An Equal Opportunity Employer" OCONEE COUNTY BOARD OF COMMISSIONERS Human Resources 7635 Macon Hwy, Suite 1200 WATKINSVILLE, GEORGIA 30677 [PHONE REDACTED] ---PAGE BREAK--- Education Check Highest Grade Completed: High School GED/USAFI 5 6 7 8 9 10 11 12 GED USAFI Name of School: Date Awarded Address: City State Last year attended Graduated? No Yes Place Where Test Was Administered Equivalency Diploma or Certificate Awarded? Name/Address of State Authority Issuing Diploma If the position you are applying for requires a college degree, or if you wish to volunteer any secondary educational information, please complete the following: Name of College: Address: Last year attended Graduated? No Yes Give highest degree received: What special vocational or business courses have you taken? Special honors: Please use this space for additional information related to your education, training and experience. References Give name, address, and telephone number of three references who are not related to you and are not previous employers. 1. Name: Telephone: ( ) Address: 2. Name: Telephone: ( ) Address: 3. Name: Telephone: ( ) Address: No Yes ---PAGE BREAK--- Work History Describe your work history beginning with your current or most recent job. Include military and volunteer experience. Failure to give complete information regarding each job held may result in your disqualification. Complete addresses with zip codes and telephone numbers for all employers are necessary. A resume may be attached only as additional information and will not be accepted in lieu of completing this section. Have you ever been disciplined or fired? No Yes If yes, why? Company Name: Telephone: Address: Employment Dates: From to Name of Supervisor: Annual Salary: Position Held: Reason for Leaving: Describe Your Duties: Company Name: Telephone: Address: Employment Dates: From to Name of Supervisor: Annual Salary: Position Held: Reason for Leaving: Describe Your Duties: Company Name: Telephone: Address: Employment Dates: From to Name of Supervisor: Annual Salary: Position Held: Reason for Leaving: Describe Your Duties: ---PAGE BREAK--- Drug Test Consent and Information Release Form I understand that one of the components of the Oconee County Drug and Alcohol Policy is a urine test for drugs and/or alcohol as a condition of employment. A positive test will result in: a) Denial of employment; b) Disciplinary Action to include termination of employment. I authorize the testing laboratory to release the results of this drug and alcohol test only to the Oconee County Medical Review Officer or designee, the Oconee County Board of Commissioners and their legal counsel, the applicable Department Head, those Oconee County employees who have a valid need to know, or those involved in any appeal process should it become necessary. I understand that this information will otherwise be kept confidential and will not be released without my written consent or as is otherwise permitted by law. I release the medical personnel and any and all of their employee/owners or representatives from any and all liabilities arising from the release or use of the information derived from or contained in my drug results. During the process of testing a urine specimen for drugs, the specimen is also tested for excessive dilution (excess water in the specimen). In order for the specimen to be a valid specimen, it must not be a dilute specimen. For 6 hours before the test, please do not drink more than 12 ounces of liquid including alcohol or caffeinated beverages (such as sodas, coffee, or tea) or take a diuretic (water pill) unless it is medically necessary. If you take diuretics prescribed by a physician, and it is medically necessary that you take the diuretic on the day of specimen collection, please inform the collector at the time that the specimen is collected. The prescription for the diuretic will need to be verified by the medical review officer if the specimen is dilute. Read, acknowledged and consented to, this day of Applicant’s Signature Applicant’s Certification and Agreement Authorization To Release Information Conditions of Employment I hereby certify that the information provided by me in this application is true and complete, and I understand that misrepresentations, omissions of facts, or falsifications on this application are grounds for refusal to hire, or if employed, may be considered as constituting grounds for disciplinary measures or termination. I authorize any person(s), firm or organization listed herein to furnish Oconee County with any and all information concerning my previous employment, education, or any other information, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability for any damage which may result from furnishing such information to Oconee County. I authorize you to request, receive, and verify all information given in this application. If I am employed by Oconee County, I agree to conform to the policies, rules and regulations of the employer set forth in the Personnel Policies of Oconee County and acknowledge that these policies, rules and regulations may be changed, interpreted, withdrawn, or added to by the employer at any time, at the employer’s sole option. I further acknowledge that if I am employed by Oconee County, my employment will be at-will and may be terminated with or without cause at any time by me or by Oconee County until I become a non-probationary employee. I also understand that I will only be considered for the position(s) I have specified on this application and that ninety (90) days from the date of this application, all consideration for employment may cease unless I notify Oconee County Human Resources that I am still interested in employment. May we contact your present employer? No Yes Not Applicable You must sign the Certification and Agreement, Authorization to Release Information and Conditions of Employment form to enable us to contact prior employers, even though we may not contact your present employer Date: Signature: Pursuant to Title II ADA and Section 504 of the Rehabilitation Act of 1973, as amended, no otherwise qualified individual with a disability in the United States shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance or under any program or activity conducted by Oconee County, Georgia. Additionally, pursuant to Title VI of the Civil Rights Act of 1964 and the Civil Rights Restoration Act of 1987, no person shall on the grounds of race, color, or national origin be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity conducted by Oconee County, Georgia.