2. 

   APPLICATION FOR EMPLOYMENT

   An equal opportunity employer

   Hancock County is an Equal Opportunity Employer, accepting applications for employment with no regard to race, gender, color, creed, religion, national origin, age, disability, marital status, or any other legally protected status. Certain jobs require Surety Bond or use of a County vehicle, and will be subject to additional screening.

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 Names You Have Worked Under?
24. In Case Of Emergency Notify:
26. First Name
27. Last Name
29. Address
31. City
32. State
33. Zip Code
35. Phone Number
39. Employment Desired
41. Position Desired
42. Start Date
    Start Date
43. Desired Salary
45. Are you employed now?

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

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

    1. Yes
    2. No
49. If yes, please list Name and Department
51. Are you a Public Employees Retirement System of Mississippi (PERS) Retiree?

    1. Yes
    2. No
53. Have you previously been employed by Hancock County?

    1. Yes
    2. No
54. If previously employed by Hancock County, please list department, position, years employed, and reason for leaving
58. Education

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

60. High School
62. College/Other Training
64. Specialized Training
68. Are you active duty, reserve, a veteran or separated from the armed forces?

    1. Yes
    2. No
69. What branch?
71. Dates enlisted?
    Dates enlisted? Start Date

    —

    Dates enlisted? End Date
72. Type of discharge and date:
76. 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. 

80. Employment History

    List your work experience below, beginning with your present or most recent employer first

82. Month/Year Employed
    Month/Year Employed Start Date

    —

    Month/Year Employed End Date
83. Company Name
85. City
86. State
88. Phone Number
89. May we Contact?

    1. Yes

    1. No
91. Position (Job Title)
92. Salary
94. Reason for Leaving
98. Month/Year Employed
    Month/Year Employed Start Date

    —

    Month/Year Employed End Date
99. Company Name
101. City
102. State
104. Phone Number
105. May we Contact?

     1. Yes

     1. No
107. Position (Job Title)
108. Salary
110. Reason for Leaving
114. Month/Year Employed
     Month/Year Employed Start Date

     —

     Month/Year Employed End Date
115. Company Name
117. City
118. State
120. Phone Number
121. May we Contact?

     1. Yes

     1. No
123. Position (Job Title)
124. Salary
126. Reason for Leaving
130. Month/Year Employed
     Month/Year Employed Start Date

     —

     Month/Year Employed End Date
131. Company Name
133. City
134. State
136. Phone Number
137. May we Contact?

     1. Yes

     1. No
139. Position (Job Title)
140. Salary
142. Reason for Leaving
146. Please list any additional skills or qualifications that you'd like to share with us
150. Personal References (Not Former Employers or Relatives)
152. Reference #1 Name
153. Occupation
154. Phone Number
156. Address
158. City
159. State
160. Zip Code
164. Reference #2 Name
165. Occupation
166. Phone Number
168. Address
170. City
171. State
172. Zip Code
176. Reference #3 Name
177. Occupation
178. Phone Number
180. Address
182. City
183. State
184. Zip Code
186. If you have a resume or other relevant information, please attach it here

188. 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 PREEMPLOYMENT 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 PREEMPLOYMENT 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 

190. 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 of the application, or dismissal, if I discovered after I am hired

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192. 1. Receive an email copy of this form.
193. Email address

     This field is not part of the form submission.

194. Submit Submit and Print

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