EVANS COUNTY APPLICATION FOR EMPLOYMENT

Date___________________

Name_________________________________________________________________SS#________________

Last First Middle

Present address___________________________________________________________________________

Street City State Zip

Phone #__________________

Are you eighteen years of age or older?_________

Are you legally eligible for employment in the U.S. A.?__________

Have you ever been convicted of a crime, excluding minor traffic offenses, which has not been dismissed or sealed by court? _______ If yes, describe in full ______________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In the past two years have you used any illegal drug? ______ If so, when and what type of drug was used __________________________________________________________________________________________ __________________________________________________________________________________________

Position(s) applied for ______________________________________________________________________

Have you ever been employed by Evans County? ______ If yes, when? _____________________________

When would you be able to begin work if employment is offered? _________________________________

Are there any experiences, skills, or qualifications which will be of special benefit in the job for which

you are applying, such military experience, licenses, etc. ? ____________________________________________________________________________________________________________________________________________________________________________________

Given reasonable accommodations, could you perform the essential job functions of the position for which you have applied? ___________

Name and Occupation

Address

Phone Number

Personal References

Record Of Education

School	Name and Address of School	Number of Years	Diploma or Degree Received
High School
College
Other

LIST BELOW PRESENT AND PAST EMPLOYMENT, BEGINNING WITH YOUR MOST RECENT.

Name and Address of Company:
From: To: Ending Salary: Reason for Leaving: Contact Name:
Phone Number	Describe Work:

Name and Address of Company:
From: To: Ending Salary: Reason for Leaving: Contact Name:
Phone Number	Describe Work:

Name and Address of Company:
From: To: Ending Salary: Reason for Leaving: Contact Name:
Phone Number	Describe Work:

I hereby give my permission to contact the employers listed on the previous page concerning my prior work experience. (Sign here) ______________________________________________________________

If there is a particular employer(s) you do not wish us to contact, please indicate which one(s). ______

_______________________________________________________________________________________

_______________________________________________________________________________________

PLEASE READ AND SIGN BELOW

The facts set forth in my application for employment are true and correct. I understand that if employed, any false statement on this application may result in my dismissal. I further understand that this application is not and is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me.

Signature of Applicant _________________________________________________________

** EVANS COUNTY IS A DRUG FREE WORKPLACE**

**EVANS COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER**

CONSENT FORM

I hereby authorize Evans County to receive any criminal and/or driving history records pertaining to me, which may be in the files of any state or local agency in Georgia.

________________________________

Full Name (Printed)

________________________________

________________________________

Address

__________ ___________ ___________ ______________________________

SEX RACE Date of Birth SOCIAL SECURITY NUMBER

______________________________

SIGNATURE

________________________________ ___________________

NOTARY DATE