City of Hattiesburg

Application for Employment

GENERAL NOTICE

The City of Hattiesburg is an equal opportunity employer and does not discriminate on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age and disability in employment. This application is valid for 180 days (6 months) from the date of submission. If you wish to be considered for employment will be required to present verification of employment eligibility as required by the Immigration Reform and Control Act. All applicants offered a position with the City of Hattiesburg will be required to successfully pass a drug/alcohol test before the offer of employment is confirmed.

GENERAL INFORMATION

Position Title* Department*
Row 1
Add
Today's Date
History with City?*
Have you ever worked for the City before?
If Yes, when?
Applied Before?*
Have you ever applied with the City before
If Yes, when?
Any Relatives?*
Do you have relatives working for the City?
If yes, whom?*
What is their relation to you?
Job Listing
How did you learn of the position(s) you have applied for?
Walk-inNewspaperJob LineFriendRelativeEmployment AgencyWeb Pageother
Hours Will Work:
Full TimePart Time
Shift Will Work:
Day ShiftNight ShiftRotating Day/Night Shift

	Position Title*	Department*
Row 1

PERSONAL INFORMATION:

Last Name*
First Name*
Middle Initial
Address*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Email
Phone Number*
Proximity to City*
Do you live within the city limits of Hattiesburg?
Over 18?*
Are you over 18 years of age?If no, employment is subject to verification that you are of minimum legal age.
Other Last Name
List any other name used while employed that is different from the name on this application (i.e.: maiden)
Drivers's License*
Do you have a valid driver's license?
Type of License
What type of license is this?
License Class
What is the license Class?
License Information
License Number Issuing State Expiration Date
row 1
Prior Felony Convictions *
Have you been convicted of a felony? Remember, a conviction Includes those offenses that you didn't have to serve jail time but just paid a fine.
YesNo
If you answered yes to the previous question, please complete the chart below for All of your prior convictions: Click on Add to add another conviction!
Date of Conviction (City, State) of Conviction Describe Nature of Offense
Row 1
Add Next Conviction
Prior Misdemeanor Convictions *
Other than minor traffic offenses, have you been convicted of a misdemeanor? Remember, a conviction Includes those offenses that you didn't have to serve jail time but just paid a fine.
YesNo
If you answered yes to the previous question, please complete the chart below for All of your prior convictions: Click on Add to add another conviction!
Date of Conviction (City, State) of Conviction Describe Nature of Offense
Row 1
Add Next Conviction
Education Record
Type of School* School Name & Address # of years Type of Degree Major
Row 1
High SchoolBusiness/TradeCollegePost GraduateGED/Other
Add additional School
Attach Resume

	License Number	Issuing State	Expiration Date
row 1

	Date of Conviction	(City, State) of Conviction	Describe Nature of Offense
Row 1

	Date of Conviction	(City, State) of Conviction	Describe Nature of Offense
Row 1

Employment History

Please list all previous employments. List Most Recent Employer FIRST. Click on Add to add additional Employments.
- Date Started
- Date Ended
- Begin Pay
- End Pay
- Employer Name
- Employer Address
- Job Title
- Description of Duties
- Supervisor's Name
- Supervisor's Work Phone #
- Reason for Leaving
Add
Current Employer*
May we contact your current employer?
YesNo
Previous Employer*
May we contact your previous employers?
YesNo
Additional Skills
In addition to your work history, what additional knowledge, skills, or abilities do you posses which you would like to be considered?

Personal References

List 3 Personal References
Name & Occupation* Address * Phone #*
row 1
Name & Occupation* Address * Phone #*
row 1
Name & Occupation* Address * Phone #*
row 1

	Name & Occupation*	Address *	Phone #*
row 1

	Name & Occupation*	Address *	Phone #*
row 1

	Name & Occupation*	Address *	Phone #*
row 1

APPLICANT'S CERTIFICATION AND AGREEMENT

PLEASE READ CAREFULLY

I hereby declare the information provided by me in this application is true and complete, and I understand that falsification of this information is grounds for refusal to hire or, if hired, cause for termination. I authorize any of the persons or organizations referenced in this application or any attached employment listing, to give the City of Hattiesburg all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability for any damage which may result from furnishing such information to the City of Hattiesburg.

In consideration for my employment with the City of Hattiesburg, I agree to conform to the rules and regulations as set forth in the City of Hattiesburg's employee handbook and acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or be added to by the City of Hattiesburg at any time, at the City's sole option and without any prior notice to me.

I further acknowledge that if I am employed by the City of Hattiesburg, my employment will be at will, and may be terminated with or without cause at any time by me or by the City of Hattiesburg.

I understand that no representative of the City of Hattiesburg has any authority to enter into any agreement for employment for any specified period of time or to assure any benefits or terms and conditions or employment other than those set forth in the employee handbook, either prior to commencement of employment or after I have become employed.

Please Read, Sign and Submit this Form! I understand falsification of information on this application is grounds for refusal to hire, or if hired, may be cause for termination. This includes, but is not limited to, my prior employment history, my felony or misdemeanor convictions and my current address (Place of Residence). I certify the information I have entered on my application for employment is true and accurate to the best of my knowledge.

Date
Signature of Applicant

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City of Hattiesburg

GENERAL NOTICE

GENERAL INFORMATION

PERSONAL INFORMATION:

License Information

If you answered yes to the previous question, please complete the chart below for All of your prior convictions: Click on Add to add another conviction!

If you answered yes to the previous question, please complete the chart below for All of your prior convictions: Click on Add to add another conviction!

Education Record

Employment History

Please list all previous employments. List Most Recent Employer FIRST. Click on Add to add additional Employments.

Personal References

List 3 Personal References

APPLICANT'S CERTIFICATION AND AGREEMENT