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What Information Can a Former Employer Release

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					                                                                          APPLICATION FOR EMPLOYMENT
                                                                           TROUP COUNTY GOVERNMENT
                                                                            Human Resources Department
                                                                      100 Ridley Avenue LaGrange, GA 30240
                                                                      Phone(706) 883-1630   Fax (706) 883-1661

INSTRUCTIONS: Please print or type all information. You MUST sign and date your application in ink. Please complete one application for each position.
Applications will be accepted for any budgeted position. This application must be filled out accurately and completely. Answer all questions. Do not
leave any question blank. If a question does not apply, write NA (not applicable). If you need additional space to answer a question fully you may attach
an 8½ by 11 inch sheet of paper. All materials submitted become the property of Troup County and will not be returned. Nothing can be added to your
application after the announcement period has closed.
All statements made on the application are subject to verification. Exaggerated, false, or misleading statements may be cause for rejection of the application
and/or termination of employment.
All qualified applications will receive consideration for employment regardless of race, color, religion, sex, age, national origin, citizenship
status, or disability.
Position Desired:                                                                                 Salary Requirement:                   Today's Date:


Last Name:                                                                       First Name:                                                                         Middle Initial:


Street Address:                                                                  City:                                                  State:                       Zip Code:


Home Phone:                                     Other Phone:                                      Social Security Number:               Email:




Will you accept:            Temporary work?                                  Part Time Work?

Except for religious observances, will you accept:                Shift work?                                     Weekends/Holidays?

Are you at least 18 years old?                                                   If you are applying for a Law Enforcement Position are you at least 21 years old?

Are you eligible to work in the U. S.?                                           If hired, what date are you available to start work?


Have you ever worked for Troup County?                                 Dates of employment:                                               Department:
Are you related to a Troup
County employee?                                  Relationship:                                                                           Department:

Do you have a current valid                                                      Have you had any traffic violations in the past 3 years?
driver's license?                                                                If yes, list type of offense and dates:

Number:

State:

Class:

Expiration Date:
(Note: Possession of a valid driver's license is not an essential function
of all employment offered by the County. Answering "No" to this question
will not necessarily bar you from being considered for employment).


Were you referred for employment with Troup County Government?
If yes, by     Georgia Dept                Troup County
whom?            of Labor:                   Website:                                    Other:



                  Troup County is an Equal Opportunity Employer and a Drug Free Workplace

Form HR101-A        Rev 06/10                                                                                                                                                     Page 1
Have you ever been convicted of a felony or a misdemeanor?                            Yes                                 No

If yes, date and nature of the offense:

Name and location of court:

 Disposition of case:
(Note: A criminal conviction will not necessarily be a bar to consideration for employment, except that a felony or domestic violence conviction will bar
employment in a law enforcement job; the disclosure of a misdemeanor conviction will not automatically result in disqualification. The nature of the offense,
how long ago it occurred, etc., are given consideration. Criminal histories will be submitted to the National Crime Information Center (NCIC) for verification.
Failure to disclose a conviction may be considered grounds for disqualification).
Within the last ten years have you ever been terminated or
asked to resign from a job?                                                           Yes                                 No
If yes, please
explain:




EDUCATION AND TRAINING
Circle highest grade completed: 1    2    3    4      5     6       7   8      9    10      11   12   13   14   15   16
High school                                                                                 GED or
diploma?                    Yes                       No                                    equivalent?                   Yes                       No


Name and location of last high school attended:

LIST SPECIAL TRAINING (BUSINESS, TRADE, VOCATIONAL, ARMED FORCES SCHOOLS, ETC.)
                                                                                         Total Months
                                  Name and Location                                       Completed                Courses or Subjects Taken             Certificates Received




LIST COLLEGES AND UNIVERSITIES ATTENDED:
                                                                             Credit Hours Received
                       Name and Location                                    Sem               Qtr          Major Degree Field or Program of Study     Type of Degree Receicved




SPECIFIC SKILLS - List below the number of years of experience operating any equipment or experience in crafts, trades, or technical professions.
If you list computer skills, be specific about the software used.

   # Years        List office and related equipment       # Years              List all other equipment operated            # Years     List crafts/trades/technical professions




Form HR101-A    Rev 06/10                                                                                                                                                   Page 2
EMPLOYMENT RECORD - List all jobs held in the last TEN years (including military service) and any other jobs relevant to the position for which you
are applying. ALL EMPLOYMENT IN LAW ENFORCEMENT MUST BE LISTED. Major changes in duties or job titles with the same employer should
be listed as separate jobs.Start with your PRESENT or MOST RECENT position and work back. BE SPECIFIC - all or part of your rating may depend on
the information you provide. Complete addresses with zip codes and phone numbers for all employers are necessary. If additional space is needed,
please use a continuation sheet.

May we contact your present employer regarding your record of employment?                Yes                                  No


(Job 1) Present or Most Recent                          Employer:

               From                        To           Address:

    Month               Year       Month         Year   City/State/Zip:

                                                        Telephone Number:                                              Fax:

Hours per week:                                         Your Job Title:

Starting Salary:               $           per          Supervisor's Name and Title:

Current/Last Salary:           $           per          Reason for Leaving:
Enter the
specific
duties
performed
on this job:

(Job 2) Previous Job                                    Employer:

               From                        To           Address:

    Month               Year       Month         Year   City/State/Zip:

                                                        Telephone Number:                                              Fax:

Hours per week:                                         Your Job Title:

Starting Salary:               $           per          Supervisor's Name and Title:

Current/Last Salary:           $           per          Reason for Leaving:
Enter the
specific
duties
performed
on this job:

(Job 3) Previous Job                                    Employer:

               From                        To           Address:

    Month               Year       Month         Year   City/State/Zip:

                                                        Telephone Number:                                              Fax:

Hours per week:                                         Your Job Title:

Starting Salary:               $           per          Supervisor's Name and Title:

Current/Last Salary:           $           per          Reason for Leaving:
Enter the
specific
duties
performed
on this job:

Form HR101-A       Rev 06/10                                                                                                                      Page 3
(Job 4) Previous Job                                                 Employer:

               From                               To                 Address:

    Month               Year            Month            Year        City/State/Zip:

                                                                     Telephone Number:                                                                   Fax:

Hours per week:                                                      Your Job Title:

Starting Salary:                    $              per               Supervisor's Name and Title:

Current/Last Salary:                $              per               Reason for Leaving:
Enter the
specific
duties
performed
on this job:

(Job 5) Previous Job                                                 Employer:

               From                      To                          Address:

    Month               Year            Month            Year        City/State/Zip:

                                                                     Telephone Number:                                                                   Fax:

Hours per week:                                                      Your Job Title:

Starting Salary:                    $              per               Supervisor's Name and Title:

Current/Last Salary:                $              per               Reason for Leaving:
Enter the
specific
duties
performed
on this job:

REFERENCES - List three references who are not relatives or former employers.
                                                                                                                                                                                           Years
                      Name and Occupation                                                                 Address                                               Telephone Number           Known




IMPORTANT: I acknowledge that the information I have supplied is correct to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or
omissions of fact may be grounds for rejection of my application or dismissal from subsequent employment. I understand that consideration for employment in this position is
contingent upon the results of a reference and background check. I therefore authorize Troup County to investigate all statements made on my application for employment and
to discuss the results of its investigations with those responsible for hiring. I further authorize Troup County to contact my former employer(s), schools(s), and any listed references
or other persons who can verify information, and I give my consent for former employer(s), school(s), and other contacted persons to respond to questions pertaining to
information on this application. Further, I release from liability such former employer(s) or other persons contacted by and providing information to Troup County.
I understand and acknowledge: (1) This application is not intended to be and is not a contract for employment; (2) If hired my employment would be of an "at will" nature, which means
that I may resign at any time and I may be discharged at any time, with or without cause; (3) Troup County maintains a drug-free workplace and I may be subject to testing for drug
or alcohol abuse pursuant to Troup County policy.




Signature of Applicant                                                                                                                                             Date

Form HR101-A       Rev 06/10                                                                                                                                                                Page 4

				
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