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Application For Employment Washington County Board of Commissioners 119 Jones Street, Sandersville, GA 31082 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application or interview process should notify a representative of the Human Resources Department. Position(s) Applied For: Date of Application: Last First Middle Mailing Street or P.O. Box City State Zip Code Home Phone: ( ) _ Mobile Phone: ( ) _ Email Address: Referral Source: (Please Check All That Apply) Walk-In Employee Advertisement Other, Explain: _ If necessary, best time to call you is: If you are under 18, can you provide a work permit? Have you ever been employed with us before? Yes No Yes No If Yes, give dates: FROM TO Are you prevented from lawfully becoming employed in this County because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment Yes No Date available for work: What is your desired salary range or hourly rate of pay? per _ Type of employment desired: Full-Time Part-Time Seasonal Temporary Will you travel if the job requires it? Yes No Will you work overtime if required? Yes No IfNO, please explain _ Driver's license number required if driving may be required in the job for which you are applying: DL#: State:. _ Yes Is this a commercial driver's license (CDL)? No. Page 1 o/4 Washington County Georgia An Equal Opportunity Employer Food Service YEAR Reset Form ---PAGE BREAK--- Employment History S . h tartmg wit your most recent emp oyer, p ease prov1 e t e o 'd h £ II owmg m orma!Ion: Employer: Telephone#: Dates Employed: From: I I Starting Job Title/Final Job Title: Compensation (STARTING) Hourly:_ Salary: _ $ Immediate Supervisor and title: Compensation (FINAL) Hourly:_ Salary: _ $ May we contact for reference? Yes No Reason for Leaving: Summarize the type of work performed and job responsibilities: Employer: Telephone Starting Job Title/Final Job Title: Immediate Supervisor and title: May we contact for reference? Yes No Reason for Leaving: Dates Employed: From: I I Compensation (STARTING) Hourly: Salary: $ Compensation (FINAL) Hourly: Salary: $ Summarize the type of work performed and job responsibilities: Employer: Telephone#: Dates Employed: ) From: I I Starting Job Title/Final Job Title: Compensation (STARTING) Hourly: Salary: $ Immediate Supervisor and title: Compensation (FINAL) Hourly: Salary: $ May we contact for reference? Yes No Reason for Leaving: Summarize the type of work performed and job responsibilities: To: To: To: I I per per I I per per I I per per Page 2 o/4 Washington County Georgia An Equal Opportunity Employer ---PAGE BREAK--- Employment History (Continued) Explain any gaps in your employment, other than those due to personal illness, injury, or disability. _ If not addressed on previous page, have you ever been fired or asked to resign from a job? Yes No If YES, please explain. Skills and Qualifications Summarize any special training, skills, licenses, and/or ce1tificates that may assist you in performing the position for which you are applying. Indicate anv foreign languages 'OU can speak, read and/or write FLUENT GOOD FAIR SPEAK READ WRITE Educational Background Starting with your most recent school attended, provide the following information: School Name (include city and state) Years Level Completed Course of Study Comoleted Diploma GED_ Degree Certification Other Diploma GED Degree Certification Other Diploma GED Degree Certification Other References List the name and telephone number of three business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you. Name Title Relationship to You Telephone # Years Known Page3of4 Washington County Georgia An Equal Opportunity Employer ---PAGE BREAK--- Related Information List professional, trade, business, or civic activities and offices held. Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veterans/reserve National Guard or any other similarly protected status. In your current or prior job, have you ever written instructions or directions to be followed by employees or customers? Yes No Not Applicable If YES, please explain: Is there any other job-related information you want us to know about you? _ Do you have relatives (*immediate family) currently employed with Washington County or *immediate family members that are elected officials? If so, please list the name(s): * Immediate family is defined as spouse, child, grandchild, parent, grandparent, brother, sister, mother-in-law and father-in-law, or any person who resides in the employee's household and who is recognized by law as a dependent of a county employee. Applicant's Statement I certify that all information I have provided are true and complete to the best of my knowledge. I authorized investigation of all statements contained in this application for employment as may be necessa1y in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 6 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time. I hereby understand and acknowledge that the employment relationship with this organization means that the Employee may resign at any time and that the Employer may discharge the Employee at any time for cause (violation of rules regulations of Employer; failure to meet the required work standards) deemed sufficient by the Employer. I also understand that false or misleading information given in my application or interview(s) may result in elimination from further employment consideration or discharge, whenever it is discovered. DO NOT SIGN UNTIL YOU HA VE READ THE ABOVE APPLICANT STATEMENT, I ce1tify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement. Signature of Applicant: Page 4 of4 Washington County Georgia Date: An Equal Opportunity Employer ---PAGE BREAK--- Joel Cochran Sheriff Mark McGraw Chief Deputy Office of the Sheriff of Washington County PROFESSIONALISM • RESPECT • ACCOUNTABILITY Post Office Drawer 30 • Sandersville, Georgia 31082 • (478) 552-4795 • Fax (478) 552-5848 CRIMINAL HISTORY RECORD INFORMATION CONSENT/INQUIRY FORM I hereby authorize the Washington County Sheriff’s Office to conduct an inquiry for the purpose(s) listed below and receive any Georgia and/or national criminal history record information, as authorized by State and Federal law. Full Name (Print) Address Sex Race Date of Birth Social Security Number This authorization is valid for days from date of signature. I, give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment. Signature Date Signature of Employment Release Agency, Title Date OFFICIAL USE ONLY – DO NOT FILL Date of Inquiry: Time of Inquiry: Operator Initials:__________ Purpose Code Used: (Check all that apply) J - Employment with criminal justice agency – civilian Z – Employment with criminal justice agency – P.O.S.T. certified The inquiry resulted in the following: (Check all that apply) No Criminal Record Available Criminal Record (Attached / Released) No NCIC/GCIC Warrant Possible NCIC/GCIC Warrant (List Wanting Agency Below) Agency Designee SIGN SIGN Female Native Hawaiian SIGN ---PAGE BREAK--- Joel Cochran Sheriff Mark McGraw Chief Deputy Office of the Sheriff of Washington County PROFESSIONALISM • RESPECT • ACCOUNTABILITY Post Office Drawer 30 • Sandersville, Georgia 31082 • (478) 552-4795 • Fax (478) 552-5848 Georgia Driver’s History Consent Form I hereby authorize the Washington County Sheriff’s Office to receive a copy of my Georgia driver’s history information as part of my application for criminal justice employment, or for use relative to the performance of my official duties with this agency. Full Name (print) Address Sex Date of Birth Driver’s License Number Signature Date SIGN Female ---PAGE BREAK--- GEORGIA CRIME INFORMATION CENTER AWARENESS STATEMENT Access to Criminal Justice Information (CJI), as defined in Georgia Crime Information Center (GCIC) Council Rule 140-1-.02 (amended), and dissemination of such information is governed by state and federal laws and the Rules of the GCIC Council. CJI cannot be accessed or disseminated by any personnel except as directed by superiors and as authorized by approved standard operating procedures. These standard operating procedures are based on controlling state and federal laws, relevant federal regulations, and the Rules of the GCIC Council. O.C.G.A. §35-3-38 establishes criminal penalties for specific offenses involving obtaining, using, or disseminating criminal history record information (CHRI) except as permitted by law. The same statute establishes criminal penalties for disclosing or attempting to disclose techniques or methods employed to ensure the security and privacy of information or data contained in Georgia criminal justice information systems. The Georgia Computer Systems Protection Act (Act), O.C.G.A. §16-9-90 et. seq., provides for the protection of public and private sector computer systems, including communications links to such computer systems. The Act establishes four criminal offenses, all major felonies, for violations of the Act: Computer Theft, Computer Trespass, Computer Invasion of Privacy, and Computer Forgery. The criminal penalties for each offense carries maximum sentences of fifteen (15) years in prison and/or fines up to $50,000.00, as well as possible civil ramifications. The Act also establishes Computer Password Disclosure as a criminal offense with penalties of one year in prison and/or a $5,000.00 fine. The Georgia Criminal Justice Information System (CJIS) Network is operated by the GCIC in compliance with O.C.G.A. §35-3-31. All databases accessible through CJIS Network terminals are protected by the Computer Systems Protection Act. Similar communications and computer systems operated by municipal/county governments are also protected by the Act. By my signature below, I acknowledge that I have read and understand this Awareness Statement. Print Name: Signed: Date: GCIC Awareness Statement Reviewed 2013/Last Revised 2010 Page 1 of 1 EMAIL FORM Reset Form