Full Text
McDuffie County Board of Commissioners Human Resources 210 Railroad Street Suite 2432 Thomson, Georgia 30824 (706) 595-2101 (706) 595-2151 Fax Web site: www.thomson-mcduffie.net All information must be completed so that applications can be given complete and equitable consideration. All qualified applicants will receive consideration for employment regardless of race, color, religion, sex, age, national origin, or disability. If you need help in filling out this form or any other state of employment please contact the Human Resources Department so that every effort may be made to accommodate you. Position Date Name Last First Middle Present Address City/State Zip Code Home Phone ( ) Alternate Phone ( ) Are you over 18? Yes No Date available for employment Will you accept: Full-time Part-time Temporary Work Shift Work Have you been previously employed by this jurisdiction? Have you been convicted of a felony within the last ten (10) years? Yes No If yes please explain (in accordance with county policy, this information will be reviewed for job relatedness). PERSONAL DATA APPLICATION FOR EMPLOYMENT GENERAL INFORMATION ---PAGE BREAK--- 2 Do you have any relatives employed by McDuffie County? Yes No If yes list name(s) and department(s) in which employed. Do you have a valid driver’s license? Yes No (Possession of a valid driver’s license is not an essential function of all employment offered by the county. Answering “No” to this question is not necessarily a bar to consideration for employment.) Have you been given a job description or had the requirements of the job explained to you? Yes No Do you understand these requirements? Yes No Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 GED: If you have a GED give the date completed and awarding agency School Name & Location Degree Received Date Completed High School College Bus/Voc. Tech Graduate School Describe special courses you have taken which relate to the job for which you are applying: List all licenses, special qualifications or skills (including language skills, typing skills, business equipment, or machine operating skills) which relate to the job for which you are applying: EDUCATION ADDITIONAL EDUCATION ---PAGE BREAK--- 3 Describe your work history with your current or most recent job. Include military and unpaid experience. Failure to give complete information regarding each job held may result in your disqualification. Complete addresses with phone numbers for all employers are necessary. Most recent employer: Address: City: State/Zip Phone # ( ) From: / To: / Salary: / Month Year Month Year Beginning Ending Job Title: Supervisor’s Name Duties: Reason for leaving or considering change: 2nd recent employer: Address: City: State/Zip Phone # ( ) From: / To: / Salary: / Month Year Month Year Beginning Ending Job Title: Supervisor’s Name Duties: Reason for leaving or considering change: 3rd recent employer: Address: City: State/Zip Phone # ( ) From: / To: / Salary: / Month Year Month Year Beginning Ending Job Title: Supervisor’s Name Duties: Reason for leaving or considering change: WORK HISTORY ---PAGE BREAK--- 4 LIST THREE REFERENCES 1. Name Address Phone # 2. Name Address Phone # 3. Name Address Phone # I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered a sufficient cause of dismissal. The county is hereby authorized to make investigation of my prior educational and work history. Date Applicant’s Signature (Must be signed for consideration) I have made application for employment with the McDuffie County Government. I authorize my former employer to give any information regarding my employment and/or any information they have regarding me, whether or not it is on their records. I hereby release them for any damages whatsoever for issuing same. There shall be no discrimination exercised on account of race, national origin, color, religion, creed, age, sex, political affiliation, or physical or mental disability with respect the recruiting and examination of applicants, hiring of eligible, or in any personnel transactions affecting employees, including training, promotion and disciplinary actions. All personnel actions shall be based solely on the ability of the individual to perform the duties of the job. We Are an Equal Opportunity Employer and Provider REFERENCES AUTHORIZATION TO RELEASE INFORMATION EQUAL OPPORTUNITY AND NON-DISCRIMINATION ---PAGE BREAK--- 5 I, , being an applicant for employment with McDuffie County, Georgia, do hereby certify that I have been provided with written notice of the McDuffie County Drug and Alcohol Testing Policy for all employees and job applicants. I understand that I have the right to provide a list of medications that I have recently used and further understand that said list of medications, if provided, shall be sealed and held as confidential unless there is a positive test result. I further understand, that in the event of a confirmed positive test result, the list of medications shall only be disclosed to the medical official who will determine whether the positive result was due to the lawful use of any of the listed medications. I do hereby further certify that I understand all of my rights under both the Constitutions and laws of the United States and the State of Georgia and my rights under the McDuffie County Personnel Policies relating to drug and alcohol testing. I further understand that I as the a job applicant whose drug test yields a positive result shall be given a second test using a gas chromatography/mass spectrometry (GC/MS) and that the second test shall use a portion of the same test sample withdrawn for use in the first test. I further understand that if the second test confirms the positive test result, a job applicant shall be notified of the results in writing by the appropriate department head or designee and that the letter of notification shall identify the particular substance found and its concentration level. I further understand that job applicant will be denied employment with McDuffie County if his/her initial positive test results have been confirmed and that job applicant will be informed in writing if he/she is rejected on the basis of a confirmed positive drug test result. I further understand that if an employee’s positive test result has been confirmed, the employee is subject to disciplinary action up to and including termination. I further understand that if an employee’s positive test result has been confirmed the employee is entitled to a hearing prior to a disciplinary action taken by McDuffie County. I have been informed that the hearing shall be conducted by an official who did not take part in the initial decision to require the drug test. I further understand that in order to receive said hearing, an employee must make a written request for a hearing to the appropriate department head or designee within ten (10) days of receipt of the confirmed test results. I understand that an employee may be represented by legal counsel, present evidence and witnesses on his/her behalf, and confront and cross-examine any witnesses testifying against him/her. I further understand that no adverse personnel action will be taken against an employee based on a confirmed positive result unless the hearing officer find by a preponderance of the evidence that: A. The employee’s supervisor had reasonable suspicion to believe that the employee was under the influence of drugs or alcohol while on the job; B. The employee’s drug test results are accurate. CONSENT TO DRUG AND ALCOHOL TESTS ---PAGE BREAK--- 6 I further understand that within ten (10) days following the close of the hearing, the hearing officer shall make a written decision and brief summary of the facts and evidence supporting that decision. I further understand that any job applicant who refuses to consent to a drug and alcohol test will be denied employment with the County. I further understand that any employee who refuses to consent to a drug and alcohol test when reasonable suspicion of drug or alcohol use has been identified is subject to disciplinary action up to and including termination. I understand that an employee, upon a written request to the appropriate department head within ten (10) days from his/her refusal, shall be entitled to a hearing prior to the County’s decision that such refusal warrants disciplinary action. I understand and have been informed that the reasons for the refusal shall be considered in determining the appropriate disciplinary action. I, , do hereby certify that I have been fully notified of McDuffie County’s drug testing policy and that I fully understand my rights under said county drug testing policy. I further hereby certify that I have read and understand this consent form and have had the opportunity to ask any questions that I might have concerning my rights, and I am fully satisfied that I have been made aware of all my rights concerning McDuffie County’s drug testing policy. I do voluntarily and of my own free will and accord hereby consent to a drug and alcohol test being administered to me. This day of , 20 . ATTESTED TO IN THE PRESENCE OF : APPLICANT