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WASHINGTON COUNTY BOARD OF COMMISSIONERS P.O. Box 271 Sandersville, GA 31082 Phone [PHONE REDACTED] · Fax [PHONE REDACTED] Email: [EMAIL REDACTED] Effective Date: January 1, 2014 MEL DANIEL Chairman HARLAN ARCHER District 1 BOBBY JACKSON District 2 JAMES HITCHCOCK, JR. District 3 FRANK SIMMONS, JR. District 4 MICHAEL BRILLHART Administrator Dear Applicant: Thank you for choosing the Washington County Board of Commissioners to help meet your employment and career goals. We appreciate the time you are taking to complete our standard application process. The Washington County Board of Commissioners is committed to providing a safe and comfortable environment for our employees, customers, and community; as well as offering all employees the security of knowing their coworkers are as trustworthy, safety oriented, and drug- free. In order to meet these safety and security goals, the Washington County Board of Commissioners, with your written authorization, also conducts a thorough background screening; in addition to drug testing all potential new employees. If you are considered for employment, please note that some or all of the following employment screenings will be performed: • A Criminal Record Check • Previous Employers and Education Verification • Professional License and Credentials Verification (if appropriate) • Driving Record Check (if your job involves driving a company or private vehicle) • Employment Credit Report (if appropriate) • Additional levels of background screening when appropriate With this in mind, if there are any issues that you feel need to be resolved before you submit your application and are considered for employment, please discuss them with us or return at another time to complete your initial paperwork. ALSO, PLEASE COMPLETE THE APPLICATION FULLY. BLANK FIELDS WILL NOT BE ACCEPTED. Again, thank you for considering employment with the Washington County Board of Commissioners. ---PAGE BREAK--- Page 1 of 4 Washington County Georgia An Equal Opportunity Employer 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: / / Name: Last First Middle Mailing Address: 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: AM/PM If you are under 18, can you provide a work permit? Have you ever been employed with us before? If Yes, give dates: 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 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____ If NO, please explain Driver’s license number required if driving may be required in the job for which you are applying: DL#: Is this a commercial driver’s license (CDL)? ---PAGE BREAK--- Page 2 of 4 Washington County Georgia An Equal Opportunity Employer Employment History Starting with your most recent employer, please provide the following information: Employer: Telephone ( Dates Employed: Starting Job Title/Final Job Title: Compensation (STARTING) Hourly:___ Salary: per Immediate Supervisor and title: Compensation (FINAL) Hourly:___ Salary: per May we contact for reference? Reason for Leaving: Summarize the type of work performed and job responsibilities: Employer: Telephone ( Dates Employed: Starting Job Title/Final Job Title: Compensation (STARTING) Hourly:___ Salary: per Immediate Supervisor and title: Compensation (FINAL) Hourly:___ Salary: per May we contact for reference? Reason for Leaving: Summarize the type of work performed and job responsibilities: Employer: Telephone Dates Employed: Starting Job Title/Final Job Title: Compensation (STARTING) Hourly:___ Salary: per Immediate Supervisor and title: Compensation (FINAL) Hourly:___ Salary: per May we contact for reference? Reason for Leaving: Summarize the type of work performed and job responsibilities: ---PAGE BREAK--- Page 3 of 4 Washington County Georgia An Equal Opportunity Employer 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 certificates that may assist you in performing the position for which you are applying. Indicate any foreign languages you 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 Completed Level Completed Course of Study 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 ---PAGE BREAK--- Page 4 of 4 Washington County Georgia An Equal Opportunity Employer 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____ 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 necessary 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 HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement. Signature of Applicant: Date: ---PAGE BREAK--- INVESTIGATION AUTHORIZATION (RELEASE) & BACKGROUND SCREENING ORDER FORM Under the applicable provisions of the federal Fair Credit Reporting Act (FCRA), notice is hereby given that a consumer report or investigative consumer report may be requested and completed, which may include information pertaining to your employment history, educational accomplishments, criminal record, driving record, credit history (only when permitted by law and where it is related to the duties and responsibilities of the position sought), character, general reputation, and personal characteristics. This report may also include information pertaining to a commercial driver’s license and commercial driving work history which, under provisions of the United States Department of Transportation, can include inquiries into drug and alcohol testing and as referenced in Parts 382.413 and 391.23. An investigation into your workers’ compensation and/or industrial accident background may also be conducted according to the provisions of the Americans with Disabilities Act (ADA) and other federal, state, and local laws, and can be requested only after a conditional job offer has been made. This entire report will be used for employment purposes only, and will be processed by LABORCHEX Companies, an employment background screening service, located at 2506 Lakeland Drive #200, Jackson, MS 39232, [PHONE REDACTED] (www.laborchex.com). LABORCHEX conducts business according to all applicable federal and state laws. LABORCHEX agrees to use its best and most precise efforts to furnish its clients (a “client” is defined as a business, company, or organization which contracts with LABORCHEX to provide employment background screening services to them) with accurate, current, complete, and reliable information based on such information as it is reasonably available and obtained via applicable public records sources and/or information services utilized by LABORCHEX. Sources also include contact by phone, FAX, U.S. Mail, and electronic mail of an applicant’s previous employers, education officials, government agencies, and other individuals/entities who can provide accurate verification and confirmation of the applicant’s background. PRIVACY NOTE: LABORCHEX does not distribute details of employment applications or results to anyone other than the client that requested the background investigation. Information provided by applicants is held by LABORCHEX in strict confidence according to all federal laws. You are further advised that LABORCHEX does not counsel its clients regarding their hiring policies and procedures. LABORCHEX will not have any knowledge as to why you have been offered a position or the reasons why you were denied employment. Under the provisions of the FCRA, you have the right to dispute information provided in a report and, after providing proper identification, you can request a copy of such report(s) from LABORCHEX, including details about the sources of information. Such information will be provided to you at no cost. The company, business, or organization at which you applied for a job must also provide a copy of the report to you, if you request it from them. I, the undersigned, have read and fully understand the above notice. I hereby authorize LABORCHEX to investigate my employment history, educational accomplishments, criminal record, driving record, credit history, character, general reputation, personal characteristics, and information pertaining to a commercial driver’s license and commercial driving work history, including inquiries into drug and alcohol testing and use, as well as workers’ compensation information (as according to federal guidelines stated above). I authorize LABORCHEX to verify the facts stated by me on the attached/forwarded application and/or resume. I understand that this release will be valid for my entire period of employment. Note: I understand that if I am a resident of CA, MA, ME, MN, NJ, NY, OK, and WA I can obtain a copy of the completed consumer report from LABORCHEX by checking this box { which will also include a document called “A Summary of Your Rights Under the Fair Credit Reporting Act (FCRA).” Please be sure to provide your full mailing address below. Print Name: Last First Middle Initial Maiden Name Date of Birth: Security (DOB and SSN used only for identification purposes to ensure accuracy of reports) Driver’s License Number BELOW IS FOR COMPANY USE ONLY Company Applicant Soc. Sec. CHECK SCREENINGS REQUIRED FOR THIS APPLICANT Previous Employment Verification (Special Screening for Commercial Drivers) Education Verification Driving Record Check Professional/Personal References Workers’ Compensation* Professional License & Credential Check Official Education Transcripts Employment Credit Report* CRIMINAL RECORD CHECKS (list jurisdictions below) CrimeChexPLUS Multi-State Criminal Index Check List Criminal Record Jurisdictions To Be Checked: National Address Search & Social Security # Validation Nationwide Federal Violations Criminal Record Check NOTE: If you are not using the website to place orders, please include the completed job application (along with a copy of this signed release) in your FAX or Email to LABORCHEX. *When permitted by state law. Signature of Official Authorizing ---PAGE BREAK--- Applicant Privacy Rights As an applicant who is the subject of a Georgia only or a Georgia and Federal Bureau of Investigation (FBI) national fingerprint/biometric-based criminal history check for a non-criminal justice purpose (such as an application for criminal justice or non-criminal justice employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. All notices must be provided to you in writing. These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code Section 552a, and Title 28 Code of Federal Regulation (CFR), 50.12, among other authorities. • You must be provided written notification that your fingerprints/biometrics will be used to check the criminal history records maintained by the Georgia Crime Information Center (GCIC) and the FBI, when a federal record check is so authorized. • You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later) when you submit your fingerprints and associated personal information. This Privacy Act Statement must explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated information will be searched, shared, or explained. • You must be advised in writing of the procedures for obtaining a change, correction, or update of your criminal history record as set forth at 28 CFR 16.34. • You must be provided the opportunity to complete or challenge the accuracy of the information in your criminal history record (if you have such a record). • If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on the information in the criminal history record. • If agency policy permits, the officials may provide you with a copy of your criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may find information regarding how to obtain a copy of your Georgia criminal history record at the GBI website: information-frequently-asked-questions Information regarding how to obtain a copy of your FBI criminal history record is located at the FBI website: • If you decide to challenge the accuracy or completeness of your criminal history record, you should contact and send your challenge to the agency that contributed the questioned information. If the disputed arrest occurred in the State of Georgia, you may send your challenge directly to the GCIC. Contact information for the GCIC can be found at criminal-history-record-information-frequently-asked-questions Alternatively, you may send your challenge directly to the FBI by submitting a request via The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenge entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.) • You have the right to expect that officials receiving the results of the criminal history record check will use it only for the authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. ---PAGE BREAK--- Privacy Act Statement This privacy act statement is located on the back of the (blue) FD-258 fingerprint card. Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principle Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety. As of 02/04/2021 ---PAGE BREAK--- Applicant Privacy Rights Notification Signature Form Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure of obtaining a change, correction or updating an FBI identification record is set forth in Title 28, Code of Federal Regulations (CFR), 16.34. Procedures for obtaining a copy of the FBI criminal history record are set forth in 28 CFR 16.30 through 16.33 or review the FBI website. Signature Print Name Date ---PAGE BREAK--- Joel Cochran Sheriff Office of the Sheriff of Washington County 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 Phone 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) E – Employment / Rental M – Working with Mentally Disabled N – Working with Elderly P – Public Records U – Personal Review W – Working with Children 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) Wanting Agency Wanting Agency Designee