Salary Certificate as per L.I.C

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Salary Certificate as per L.I.C Powered By Docstoc
					Page 1 of 6                                                                                 EMPLOYMENT APPLICATION FORM - OPEN




                                                                                                                          OC#

                                                                                                                                            ANNC#
              Employment Application for OPEN COMPETITIVE Positions
                          The Mobile County Merit System
                                                An Equal Opportunity Employer


     IMPORTANT INSTRUCTIONS:
     1. Read the job announcement carefully and submit all required documents with your application.
     2. Fill out all forms in INK or TYPEWRITE. Be sure that you answer ALL QUESTIONS accurately, completely and




                                                                                                                          LAST NAME
        legibly.
     3. INDIVIDUAL APPLICATION PACKETS must be completed and submitted for
        EACH JOB ANNOUNCEMENT along with SEPARATE COPIES OF ALL SUPPORTING
        DOCUMENTATION including, but not limited to, transcripts, certificates, and DD214 forms.

                               RESUMES SHOULD NOT BE SUBMITTED OR
                          REFERENCED IN LIEU OF A COMPLETED APPLICATION.


       POSITION FOR WHICH APPLICATION IS MADE:                                           DO NOT WRITE IN THIS BLOCK
                                                                                           (for Department use only)
       Announcement #:
                                                                                   Application Accepted By: _______




                                                                                                                          FIRST
       Job Title:                                                                  Application Screened By: _______

       Closing Date:                                  or

              Check if OPEN CONTINUOUSLY (See Job Announcement)



                                   APPLICANT                     INFORMATION




                                                                                                                          MIDDLE
     1. Name
                                Last                          First                                 Middle

     2. Social Security Number

     3. Address


                                                                                                                        SSN
                                Street or RFD                      City/Town                  State          Zip Code

     4. Phone: Home (                  )                           Business (        )

                          E-mail Address:

     5. Do you have a current valid Driver’s License from your state of residence?                    YES          NO

     6. Are you claiming veteran’s preference?                                                        YES          NO
                                                                                                                        TITLE OF POSITION




               Did you receive an honorable discharge?                                                YES          NO
               (Include active military service in the employment record section.
                 See information sheet entitled “Important Information for All
                 Applicants” for proof of veteran’s preference eligibility requirements.)

     7. Are you a current Mobile County Merit System employee?                                        YES          NO

     8. Do you hold any political office?                                                             YES          NO
          If yes, date of election or appointment                                   Title
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       Page 2 of 6                                                                  EMPLOYMENT APPLICATION FORM - OPEN


        Name: _____________________________ SSN: ________________________ Announcement # ______________

                                  APPLICANT                 I N F O R M A T I O N (continued)

        9. List anyone to whom you are related by blood or marriage who is employed by a local government
           agency (Mobile County Merit System Agency) or who is an elected or appointed official within
           Mobile County (include members of Boards, Councils or Commissions).

                     NAME                    RELATIONSHIP              EMPLOYER               POSITION OR TITLE




        NOTE: In answering questions 10 and 11, ALL PREVIOUS OR CURRENT offenses and jobs are to be considered
        without exception. A "yes" response to the following questions does not automatically disqualify you from employment
        consideration. All facts provided will be evaluated.

                                 Failure to reveal requested information is a cause for disqualification.

        10. A. Have you received any traffic tickets within the last five years?          YES               NO
               If yes, give complete details for EACH and EVERY TICKET
               to include date, charge, city & state, court and action taken.




            B. Have you ever been convicted of any other offense against the law?         YES               NO
                 If yes, include date, type of conviction (misdemeanor or felony),
                 charge, city & state, and action taken.




            C. Are you now under charges for any unlawful act? If yes, explain.           YES               NO




        11. Have you ever been fired, discharged or forced to resign from a job?          YES               NO
            If yes, give complete details to include employer, date, and reason.




                                 Failure to reveal requested information is a cause for disqualification.

        12. Applicants proficient in languages other than English may receive preference. What languages do you:

            A. Speak fluently
            B. Read and write proficiently

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    Page 3 of 6                                                                                    EMPLOYMENT APPLICATION FORM - OPEN

     Name: _____________________________ SSN: ________________________ Announcement # ______________

                                                         EMPLOYMENT HISTORY
IMPORTANT INSTRUCTIONS: Start with your present employment and work back. Include ALL previous employment, i.e., full-time, part-
time, self-employed and military service, as well as periods of unemployment. Attach additional sheets if necessary. Proper mailing
addresses of all employers are the responsibility of the applicant. Failure to provide Employment Dates, Titles, Duties,
Responsibilities, Hours Worked per Week and Reason for Leaving may cause disqualification.
Submit all required documents with your application including the Supplemental Questionnaire. Answer ALL QUESTIONS accurately,
completely, and legibly. All documents will be evaluated and verified relative to qualifications claimed.
RESUMES SHOULD NOT BE SUBMITTED OR REFERENCED IN LIEU OF A COMPLETED APPLICATION.

EMPLOYMENT RECORD—May we contact your present employer?                              YES             NO             UNEMPLOYED

     (1) Dates of Employment                           Name & Address of Employer:                      Exact Title of Position
                  MONTH            YEAR
         FROM:
         TO:                                                                                            Number of Employees
                                                                                                        You Supervised:

         Name & Title of Your Immediate Supervisor:                                            (Name)                             (Title)
         Salary or Earnings— STARTING: $                                                   Average Hours Worked Per Week:
                                 FINAL: $
         Reason for Leaving:
         Description of Duties and Responsibilities:




     (2) Dates of Employment                           Name & Address of Employer:                      Exact Title of Position
                  MONTH            YEAR
         FROM:
         TO:                                                                                            Number of Employees
                                                                                                        You Supervised:

         Name & Title of Your Immediate Supervisor:                                            (Name)                             (Title)
         Salary or Earnings— STARTING: $                                                   Average Hours Worked Per Week:
                                 FINAL: $
         Reason for Leaving:
         Description of Duties and Responsibilities:




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     Page 4 of 6                                                                             EMPLOYMENT APPLICATION FORM - OPEN

      Name:_____________________________ SSN:________________________ Announcement #________________


                                               EMPLOYMENT HISTORY (Continued)

        (3) Dates of Employment                          Name & Address of Employer:                Exact Title of Position
                     MONTH            YEAR
            FROM:
            TO:                                                                                     Number of Employees
                                                                                                    You Supervised:

           Name & Title of Your Immediate Supervisor:                                      (Name)                             (Title)
           Salary or Earnings— STARTING: $                                             Average Hours Worked Per Week:
                                   FINAL: $
           Reason for Leaving:
           Description of Duties and Responsibilities:




        (4) Dates of Employment                          Name & Address of Employer:                Exact Title of Position
                     MONTH            YEAR
            FROM:
            TO:                                                                                     Number of Employees
                                                                                                    You Supervised:

           Name & Title of Your Immediate Supervisor:                                      (Name)                             (Title)
           Salary or Earnings— STARTING: $                                             Average Hours Worked Per Week:
                                   FINAL: $
           Reason for Leaving:
           Description of Duties and Responsibilities:




        (5) Dates of Employment                          Name & Address of Employer:                Exact Title of Position
                     MONTH            YEAR
            FROM:
            TO:                                                                                     Number of Employees
                                                                                                    You Supervised:

           Name & Title of Your Immediate Supervisor:                                      (Name)                             (Title)
           Salary or Earnings— STARTING: $                                             Average Hours Worked Per Week:
                                   FINAL: $
           Reason for Leaving:
           Description of Duties and Responsibilities:




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       Page 5 of 6                                                                                         EMPLOYMENT APPLICATION FORM - OPEN

        Name:_____________________________ SSN:________________________ Announcement #________________


                                                                EDUCATION HISTORY

             Important: Include with your application copies of transcripts for college or university coursework and copies of
                        certificates for business or trade schools.

     EDUCATION—Mark the highest grade completed:
     1 2 3 4 5 6 7 8 9 10 11 12 / GED /                                                 College 1 2 3 4 /                    Graduate School 1 2 3 4

      SCHOOLS            NAME AND LOCATION                     DATES ATTENDED                 GRADUATED              DEGREE                MAJOR/MINOR

                                                                                                Yes
      High School
                                                                                                No


       College                                                                                  Yes
         Or
      University                                                                                No


                                                                                                Yes
       Graduate
                                                                                                No


       Business                                                                                 Yes
          Or
        Trade                                                                                   No


     Professional Registrations/Licenses/Certifications: (Examples: CPA, RN, EMT, PE, Licensed Electrician) Include license number, date of original licensure
     and expiration date of current licensure.




  Application Source: How did you learn about us? Please check the correct number(s) and provide appropriate information below.

      (1) “Current Vacancies” Sheet                         (6) Co-worker, Friend or Relative                      (11) Job/Career Fair
                                                                                                                        (Event)
      (2) Newspaper/Journal Ad                              (7) Current or Former Employee
                                                                                                                   (12) College/University
                                                            (8) School Counselor/                                       (Location)
      (3) Television                                            Placement Office
                                                                                                                   (13) Personnel Board Website
      (4) Radio                                             (9) Other Source
                                                                                                                   (14) Other Website
      (5) Employment Agency
                                                            (10) Walk-in


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      Page 6 of 6                                                                                   EMPLOYMENT APPLICATION FORM - OPEN


         Name:_____________________________ SSN:________________________ Announcement #________________


             I have completed, attached, and/or submitted the following documents as a requirement for application for the position
             indicated:

                      Employment Application
                      (Indicating type of position applied for and announcement number)
                      Supplemental Questionnaire                                                                       Department Verification:
                      Applicant Data Sheet
                      Supporting Documents (i.e., transcripts, certificates, licenses, DD214)
                                                                                                                                 (Initials)
                              Transcripts                               _
                              DD214                                     _
                              Driver’s License                          _
                              Commercial Driver’s License               _
                              Other documents (please specify, i.e., licenses, certificates, etc.)
                                        _______________, _______________, _______________, _______________
                      Applicant Affirmative Action Data Form (Completion is voluntary.)


              I have received study materials for one of the following positions:

                        _     Firefighter
                        _     Law Enforcement Positions
                        _     Community Resource Officer
                    _____     Public Safety Dispatcher I
                        _     Public Safety Officer
                        _     School Traffic Officer


                                                             Applicant’s Signature                                            Date




          READ THIS CERTIFICATE BEFORE SIGNING:

                    I hereby certify that all information in this application is true to the best of my knowledge and I understand that any material
                    misstatement of fact will cause the loss of all rights of employment under the jurisdiction of the Personnel Board for Mobile County.
                    I agree that this Application and all papers in connection with the examination shall be confidential records of the Personnel Board
                    subject to the inspection of the appointing authority as provided by the rules and to my personal inspection as provided by the rules.
                    I further understand that eligibility will be subject to meeting suitability requirements regarding character and record of employment.
                    I understand that I will be required to pass a physical and medical examination if accepted for appointment.




               ________________________________                  _____________________________________________________
                           Date                                                        Signature


da/Applications, Revised 05-01-2007
        Mobile County Personnel Board – Applicant Affirmative Action Data Form

                                      Completion of this form is voluntary

The Mobile County Personnel Board will provide equal opportunity through a positive and continuing
program for all persons. Discrimination on the basis of race, creed, color, religion, sex, national origin,
disability, age or any other factor which cannot be lawfully used as the basis for employment decisions
is prohibited.

Federal laws and regulations require employers to monitor and report the status of their equal
employment opportunity and affirmative action programs on a continuing basis. Therefore, we are
asking you to complete the information below. This information will be maintained only for the purpose
of monitoring and reporting compliance in accordance with applicable laws and regulations and will not
be used for any other purpose.



Name:
         Last                                      First                                  Middle

Social Security Number:


Position Applied For:


Job Announcement Number:




DATE OF BIRTH:                                                           SEX:            Male            Female
                           Month        Day            Year


ETHNIC ORIGIN:                        American Indian or Alaska Native       Hispanic or Latino

(Check One)                           Asian                                  Native Hawaiian or Other Pacific Islander

                                      Black or African American              White

                                      Other




da/Applications, Revised 01/21/2010
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