Employment Application

Contact Information

1. First Name
2. Middle Name
3. Last Name
4. Address
5. City
6. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7. Zip
8. Phone
9. Email
10. Position you are applying for: Choose an open position. Assistant to Engineer/Engineering Technician Part-time Custodian Are you looking to apply for a job in the Assessor's Office? A printed employment application is required.
11. Date Available
12. Are you 18 or Older? Please Select Yes No
13. Do you have a legal right to work in the United States full-time? Please Select Yes No
14. Have you ever been employed by Chickasaw County? Please Select Yes No
Employed Start Date:
Employed End Date:
Employed Position
Reason for Leaving

Education

High School

15. Name and Location
16. Did you Graduate? Please Select Yes No No, but received GED

College or Trade School

17. Name and Location
18. Did you Graduate? Please Select Yes No
19. Major/Subject

Employment History

List employment from the past 10 years, starting with your most recent job. Account for any time period that you were unemployed by stating the nature of your activities.

Employer 1

20. Employer Name
21. Job Title
22. Address
23. City
24. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
25. Zip
26. Phone
27. Start Date
28. End Date
29. Current/Ending Pay
30. Supervisor Name
31. Work Performed
32. Reason For Leaving
33. Can we contact current employer? Please Select Yes No
Add Employer

Employer 2

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor Name

Work Performed

Reason For Leaving Add Employer

Employer 3

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor

Work Performed

Reason For Leaving

Additional Employers

Optional: Upload Resume

34. Resume
    only PDF files are allowed

Additional Information

35. List any professional, trade groups, organizations, machinery/tools operated in the past, and/or special skills that you consider relevant to your ability to perform this job.
36. Were you in the Military? Please Select Yes No
Branch
Do you have any experience from your military service that would be relevant to the job(s) for which you are applying? If yes, please explain:

---

37. Have you ever been convicted of a felony?
    For purposes of these questions, convicted includes plead guilty, plead no contest, or been given a deferred sentence of judgment. Please Select Yes No
If yes, please explain.
Note: A conviction will not automatically disqualify an applicant for a particular job and that the type and seriousness of the crime, the frequency of violoations, the date of conviction, and the applicant's entire work and educational history will be considered.

---

Job Description

38. Have you read the job description? Please Select Yes No
39. Do you understand the requirements? Please Select Yes No
40. Can you perform the requirement of this job with or without reasonable accommodations? Please Select Yes No

Driver's License

41. If the job requires, do you have the appropriate valid driver's license? N/A Yes No
Driver's License #
License Type
State of License Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Have you had any moving violations? Please Describe:

Applicant's Statement

By typing my name below, I certify that answers given herein are true and complete.

I authorize investigations of all statements contained in this Application for Employment as may be necessary in arriving at an employment decision.

I authorize Chickasaw County to conduct a check of the status of my driver’s license and my driving record and agree to sign a separate authorization for this specific purpose.

This Application for Employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Chickasaw County is “at will,” which means that the Employee may resign at any time, and the Employer may discharge the Employee at any time with or without cause. It is further understood that the “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of Chickasaw County.

I understand that any offer of employment that is extended to me is considered to be a conditional offer and is subject to successful completion of all required background checks. Identifying information such as my social security number and driver’s license number will be requested at the post-offer, pre-employment stage.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I will be required to abide by all rules and regulations of the Employer.

I agree to give Chickasaw County permission to complete appropriate background checks and agree to sign separate permission/authorization forms so that this can be accomplished.

Your Signature

42. Signature Please type your full name to serve as an electronic signature.
43. Today's Date