Form Center

2. HANCOCK COUNTY E911 APPLICATION FOR EMPLOYMENT
   
6. Personal Information
8. First Name
9. Middle Name
10. Last Name
12. Address
14. City
15. State
16. Zip Code
18. Phone Number
19. Alternate Phone Number
21. Email Address
22. Any other name(s) you have worked under?
24. Driver's License Number:
25. State Issued:
26. Expiration Date:
30. Are you a citizen of the United States of America?

    1. Yes
    2. No
34. In Case of Emergency Notify:
36. First Name
37. Last Name
39. Address
41. City
42. State
43. Zip Code
45. Phone Number
49. Employment Desired
51. Position Desired?
52. Start Date
    Start Date
53. Desired Salary
55. Are you employed now?

    1. Yes
    2. No
56. If so, may we contact your employer?

    1. Yes
    2. No
58. Do you have a Relative Working for the County?

    1. Yes
    2. No
59. Do you have an issue working days or nights?

    1. Yes
    2. No
61. Are you a Public Employees Retirement System of Mississippi (PERS) Retiree?

    1. Yes
    2. No
63. Have you applied for a position here before?

    1. Yes
    2. No
64. If yes, when?
66. Have you previously been employed by Hancock County?

    1. Yes
    2. No
67. If previously employed by Hancock County, please list department, position, years employed, and reason for leaving.
71. Employment experience:

    Start with your present or last job. Include military assignments.

73. Month/Year Employed
    Month/Year Employed Start Date

    —

    Month/Year Employed End Date
74. Company Name
76. City
77. State
78. Phone Number
80. Position (Job Title)
81. Salary
83. Reason for Leaving
85. May we Contact?

    1. Yes
    2. No
89. Month/Year Employed
    Month/Year Employed Start Date

    —

    Month/Year Employed End Date
90. Company Name
92. City
93. State
94. Phone Number
96. Position (Job Title)
97. Salary
99. Reason for Leaving
101. May we Contact?

     1. Yes
     2. No
105. Month/Year Employed
     Month/Year Employed Start Date

     —

     Month/Year Employed End Date
106. Company Name
108. City
109. State
110. Phone Number
112. Position (Job Title)
113. Salary
115. Reason for Leaving
117. May we Contact?

     1. Yes
     2. No
121. Month/Year Employed
     Month/Year Employed Start Date

     —

     Month/Year Employed End Date
122. Company Name
124. City
125. State
126. Phone Number
128. Position (Job Title)
129. Salary
131. Reason for Leaving
133. May we Contact?

     1. Yes
     2. No
137. Have you ever been dismissed, or asked to resign, from any employment?

     1. Yes
     2. No
139. If yes, explain:
143. Education and/or Training:

     Please list name and location, years attended, date graduated & subjects studied.

145. High School
147. College/Other Training
149. Specialized Training
151. List any programs or studies you have attended:
155. Are you active duty, reserve, a veteran or separated from the armed forces?

     1. Yes
     2. No
156. Type of discharge and date:
160. Have you ever been convicted of, or plead guilty or no contest to a crime? This does not include minor traffic violations.

     1. Yes
     2. No

     *conviction does not equate to disqualification for employment. Each instance will be taken into consideration in regards to the job which you are applying for.

164. Personal References (Not Former Employers or Relatives)
166. Name
167. Occupation
168. Phone Number
170. Address
172. City
173. State
174. Zip Code
178. Name
179. Occupation
180. Phone Number
182. Address
184. City
185. State
186. Zip Code
190. Name
191. Occupation
192. Phone Number
194. Address
196. City
197. State
198. Zip Code
202. Name
203. Occupation
204. Phone Number
206. Address
208. City
209. State
210. Zip Code
212. If you have a resume or other relevant information, please attach it here
214. PLEASE READ CAREFULLY APPLICANT'S CERTIFICATION & AGREEMENT

     As part of our normal procedure in processing applications, a routine inquiry will be made concerning your background. Former employers, school record offices and personal, school and employment references may be contacted to verify and obtain information concerning your background, qualifications will be used to help make a fair employment decision. This information will only be available to those participating in this decision or those who process employment applications. As part of this investigation, a check of criminal records, motor vehicle records and financial credit will also be conducted. I hereby authorize the employer, its representatives, employees or agents to conduct all pre-employment inquiries and tests as described. I further authorize the employer and its ages to verify all statements contained in this application and any other materials I submit in connection with my employment application. I agree to complete any requisite authorization forms. I release the employer, its agents and all providers of information from any liability arising out of the gathering and use of such information. In the event of employment, this authorization and release is valid throughout my employment and a photocopy is as effective as the original. I understand all offers of employment are conditional upon satisfactory reference checks, successful completion of all pre-employment tests and production of all documents necessary for the employer to verify my identity and work authorization in accordance with the requirements of the immigration and naturalization services. I understand Hancock County is a drug free workplace. I understand that I may be subject to drug testing in the future, including random testing, pursuant to policies of Hancock County. I hereby agree, on request to undergo physical examination by a physician designated by Hancock County at the county’s expense. I understand that any physical or medical exam will be post offer employment. I also agree to undergo future physical examinations that the county may require for continued employment. I certify that the information I have provided on this application is accurate and complete. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. I understand that acceptance of this application by the employer neither expresses nor implies I will be offered employment. I understand my employment is at will and I may resign at any time for any reason; similarly, my employment may be terminated by the county at any time for any reason. Any changes to the at-will employment agreement will not be valid unless in writing signed by me and a duly authorized representative of this employing organization.

216. Signature Acknowledgement

     By typing my name above, I certify the information provided is true and correct. In addition, I understand that this employment application is not an employment contract. I understand that misrepresentation or omission of facts called for is cause for rejection, or dismissal, if discovered after I am hired.

Leave This Blank:


218. 1. Receive an email copy of this form.
219. Email address

     This field is not part of the form submission.

220. Submit Submit and Print

* indicates a required field