Human Resources Information
Resume:
GLYNN COUNTY BOARD OF COMMISSIONERS
PUBLIC SAFETY APPLICATION FOR EMPLOYMENT
Human Resources Department
W. Harold Pate Courthouse Annex
**** ******** ******, ***** *** Brunswick, GA 31520
Telephone: 912-***-****
Email: ****@***********-**.*** * Web Page Address: www.glynncounty.org
INSTRUCTIONS AND INFORMATION
PLEASE READ CAREFULLY BEFORE BEGINNING
1.Please complete this application by printing or typing.
2.You will not be considered for employment in any Public Safety Position if any of the following exist:
A.Conviction in any court for any felony offense
B.Conviction in any court for any drug related offense
C.Any pending criminal action in any court
D.Presently under investigation for any criminal offense by this or any other law enforcement or criminal justice agency
E.If you are not eligible to work in the United States
3.If you have any questions regarding this application, contact the Human Resources Department at 912-***-****.
4.The following is a checklist for your convenience. We urge you to use it, as an incomplete application may not be processed. Upon completion of the application, refer to this checklist to make sure no information has been omitted.
All questions are answered. Those not applying to me are marked “N/A” or “No”.
The application is signed, dated, and notarized. Our office has several notaries for your convenience.
I have attached a copy of the following documents:
Recent Photograph
Copy of Birth Certificate
Copy of DD-214 (if applicable)
Copy of High School Diploma or State Issued GED*
Copy of Driver’s License
Copy of Social Security Card
*If hired, an official high school transcript or official copy of GED test scores will be required before beginning employment.
Glynn County has adopted a Tobacco-Free Hiring Policy effective March 1, 2009.
GLYNN COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER
PERSONAL DATA
Last Name First Name Middle Name
Present Address
Street and Number
City, State, Zip
How long have you lived there?
Years Months
Home Telephone Number
Email Address
Cellular Telephone Number
Message Telephone Number
Position Desired:
When are you available for work?
BASIC BACKGROUND INFORMATION
List any other names which you have used and which will be necessary to verify your prior employment.
If hired, can you provide proof that you are legally entitled to work in the U.S. YES NO
If not, what steps must be taken for you to begin employment lawfully?
May we contact your current employer?
YES NO
If no, please explain.
Have you ever worked for Glynn County Board of Commissioners? YES NO
If yes, give dates and position.
Do you have any relatives working here?
YES NO
If yes, give relationship and department.
Do you have any friends working here?
If yes, give department.
Do you have any commitments, including but not limited to, a non-compete or non-solicitation or confidentiality agreement with any current or former employer which may affect or restrict your employment or ability to perform the duties for which you are hired? YES NO
If yes, explain:
EDUCATION
Please list School Name:
Years Completed
Diploma/Degree
Course of Study or Major
List Degree, Specialized Training and Extra-Curricular Activities
Elementary
5 6 7 8
High School
9 10 11 12
College/University
1 2 3 4
Graduate/Professional
1 2 3 4
Trade or Correspondence
AUTHORITY TO RELEASE INFORMATION TO THE
GLYNN COUNTY BOARD OF COMMISSIONERS
To Whom It May Concern:
I hereby authorize the Glynn County Board of Commissioners or other authorized representative or Glynn County Government bearing this release, or copy thereof, within one year of its date, to obtain any information in your files pertaining to my employment and/or educational records, including but not limited to, academic achievement, attendance, athletic, and disciplinary records. I hereby direct you to release such information upon request of bearer. This release is executed with full knowledge and understanding that the information is for the official use of the Glynn County Board of Commissioners. Consent is granted for the Glynn County Board of Commissioners Human Resources Department to furnish such information as is described above, to third parties in the course of fulfilling its official responsibilities. I hereby release you, as the custodian of such records, and any school, college, university, or their education institution, or other consumer reporting agency, or retail business establishment including its officers, employees, or related personnel, both individually or collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because compliance with this authorization and request to release information, or any attempt to comply with it. Should there by any questions as to the validity of this release, you may contact me at the address or phone number listed below.
I understand that my application will be subject to verification through a comprehensive background investigation, a part of which may be a polygraph.
Falsification and/or misrepresentation of facts during any phase of the employment process will be grounds for termination of applicant’s employment process and/or dismissal.
FULL NAME:
(Signature)
FULL NAME:
(Print or Type)
SOCIAL SECURITY NUMBER:
***-**-****
PHONE NUMBER:
CURRENT ADDRESS:
1028 Buckingham Terr
DRIVER’S LICENSE NUMBER: STATE:
052299002
NOTARY PUBLIC:
(Must have Signature and Seal)
ATTACH BIRTH CERTIFICATE
This identification must show the full name and date of birth of the applicant. If the applicant is a naturalized citizen, copies of the naturalization papers are to be sent with the birth certificate.
MILITARY SERVICE
ATTACH MILITARY DISCHARGE OR DD-214 SHOWING TYPE OF DISCHARGE HERE. IF NO PRIOR MILITARY SERVICE, PLEASE MARK N/A BELOW
ATTACH COPY OF DRIVER’S LICENSE HERE
ATTACH COPY OF SOCIAL SECURITY CARD HERE
ATTACH RECENT PHOTOGRAPH HERE
PREVIOUS ADDRESSES
List the information requested regarding all addresses at which you have resided within the past 15 years. Begin with most recent. Attach additional pages if necessary.
Address: From/to
Own or Rent If rent, list landlord’s name:
Landlord’s address and phone:
Roommates:
Address: From/to
Own or Rent If rent, list landlord’s name:
Landlord’s address and phone:
Roommates:
Address: From/to
Own or Rent If rent, list landlord’s name:
Landlord’s address and phone:
Roommates:
Address: From/to
Own or Rent If rent, list landlord’s name:
Landlord’s address and phone:
Roommates:
Address: From/to
Own or Rent If rent, list landlord’s name:
Landlord’s address and phone:
Roommates:
PUBLIC SAFETY EMPLOYMENT HISTORY
List any previous employment history you have had in the Public Safety field. Include Military Service if applicable. If no prior Public Safety Employment history, please mark N/A. Attach additional pages if necessary.
Name/Address/Phone Number of Employer
From mo/yr to mo/yr Position Supervisor
Reason for Leaving-Give Details
Beginning Pay Ending Pay
Name/Address/Phone Number of Employer
From mo/yr to mo/yr Position Supervisor
Reason for Leaving-Give Details
Beginning Pay Ending Pay
Name/Address/Phone Number of Employer
From mo/yr to mo/yr Position Supervisor
Reason for Leaving-Give Details
Beginning Pay Ending Pay
PREVIOUS WORK HISTORY OTHER THAN PUBLIC SAFETY
List the names of your present or previous employers from at least the last 15 years in chronological order with present or last employer listed first. Include part-time and seasonal employment. Be sure to account for all periods of time, including any period of unemployment. If self-employed, give company name and supply business references. DO NOT ANSWER “SEE RESUME.” Fill out this form completely. Incomplete or illegible applications will be rejected. Attach additional pages if necessary.
Name/Address/Phone Number of Employer
From mo/yr to mo/yr Position Supervisor
Reason for Leaving-Give Details
Beginning Pay Ending Pay
Name/Address/Phone Number of Employer
From mo/yr to mo/yr Position Supervisor
Reason for Leaving-Give Details
Beginning Pay Ending Pay
Name/Address/Phone Number of Employer
From mo/yr to mo/yr Position Supervisor
Reason for Leaving-Give Details
Beginning Pay Ending Pay
RELEVANT TRAINING
Describe any specialized training, qualifications, apprenticeships and extra-curricular activities which relate to the job for which you are applying.
Are you fluent in Reading Writing Speaking a language other that English? If yes, what language(s).
CERTIFICATIONS
List any professional certifications, designations, licenses or courses that may be applicable to the position for which you are applying. Include certifications, licenses and courses for CPR/First Aid, Firefighter, Police Officer, Communication Officer, Detention Officer or Emergency Medical Technician. Also include any expired certifications or licenses. Attach additional pages if necessary.
Type of Certification, Course or License
State of Certification
Certification Date
Expiration Date
COMPUTER SKILLS
Please mark any of the following software programs you are fluent in using.
Microsoft Word Microsoft Excel Microsoft Access PowerPoint
Microsoft Outlook Publisher WordPerfect Adobe
Other Other
Other Other
Check any of the following areas in which you have received specialized training:
Typing Skills
Stress Management
Supervision/Management/Leadership
Customer Service/Dealing with Difficult People
Report Writing
Please give dates and details for any areas marked:
CRIMINAL RECORD
List all felony and misdemeanor convictions, whether civilian or military below. Include DUI/DWI and no contest “nolo” convictions. Attach additional pages if necessary.
Crime Court Date
Disposition of case (dismissed, sentence, paid fine, probation)
Crime Court Date
Disposition of case (dismissed, sentence, paid fine, probation)
Crime Court Date
Disposition of case (dismissed, sentence, paid fine, probation)
Are any charges currently pending against you? YES NO
If you answered yes, please give details of pending charges. Attach additional pages if necessary.
TRAFFIC CONVICTIONS
Crime Court Date
Disposition of case (dismissed, sentence, paid fine, probation)
Crime Court Date
Disposition of case (dismissed, sentence, paid fine, probation)
POSITION REQUIREMENTS:
This position may require you to:
Wear a uniform. Do you object to doing so? YES NO
Work a rotating shift. Do you object to doing so? YES NO
Work overtime. Do you object to doing so? YES NO
FINGERPRINT HISTORY:
If you have ever been fingerprinted by a police agency other than for an arrest, give details below. Your answers will be checked with the F.B.I. and other agencies.
Agency: Date: Purpose
Agency: Date: Purpose
ILLEGAL SUBSTANCE USE:
Have you ever used marijuana? YES NO
If yes, when was the date you last used marijuana?
How many times have you used marijuana in your lifetime?
What were the circumstances?
Have you ever used any other illegal drugs or used legal drugs in an illegal manner? YES NO
If yes, what were the circumstances?
TERMINATIONS
Have you ever been fired from or permitted to resign employment for breach of trust, embezzlement, theft, or any other crime? YES NO
Have you ever been fired from or permitted to resign employment for abuse of authority or for any disciplinary reasons? YES NO
Please give details if “YES” was marked for above questions:
DRIVING INFORMATION
Do you have a current valid driver’s license? YES NO
If yes, License Number State Expiration Date
Has your license ever been suspended or revoked? YES No
If yes, please explain:
Do you have personal automobile insurance? YES NO
List all moving traffic violations in the last five years. Attach additional sheets if necessary.
Offense
Date
Location
Comments
PERSONAL REFERENCES
Give the names, addresses and telephone numbers of three (3) references that are not related to you and are not previous employers.
Name
Address
Telephone Number
How you Know Person
APPLICANT’S STATEMENT
I understand that the Glynn County Board of Commissioners is committed to providing equal opportunity in all employment practices, including but not limited to selection, hiring, promotion, transfer, and compensation to all qualified applicants and employees without regard to age, race, color, national origin, sex, religion, handicap, disability, or any other category protected by federal, state or local law.
I authorize former and present employers, work and personal references listed in the application, and any other individuals I may name, to give the Glynn County Board of Commissioner or its designee any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release such parties from all liability for any damages that my result from furnishing same to the Company. I also authorize the Glynn County Board of Commissioners to provide truthful information concerning my employment with it to future employers and I agree to hold it harmless for providing such information.
I understand that the Glynn County Board of Commissioners reserves the right, to the extent permitted by law, to require drug or alcohol screening test of an applicant or an employee either prior to employment or any time during employment (as permitted by law) and I hereby give my consent to any such tests. I consent to the release of the results of any such tests to the Glynn County Board of Commissioners of its designee. I release the Glynn County Board of Commissioners and its designee from any and all liability and damages which may result or arise from any drug test or the provision of information in connection with such test.
I understand that I may be required, to the extent permitted by law, undergo a post-offer, pre-employment physical examination or psychological examination, and I hereby give my consent to such an examination.
I am fully aware and understand that, if hired, my employment is terminable at will until I become a non-probationary regular employee; that my employment is not for a definite period; and that any compensation is not for a definite period at any stated amount.
By my signature below I attest that the information given by me on this application and during the interview process is true and complete in all respects, and I agree that if the information is found to be false, misleading, incomplete, or unsatisfactory in any respect (as determined by the Glynn County Board of Commissioners in its sole judgement) I will be disqualified from consideration for employment or subject to immediate dismissal if discovered after I am hired.
DATE: APPLICANT’S SIGNATURE:
THIS APPLICATION WILL BE CONSIDERED “ACTIVE” FOR A MAXIMUM OF TWELVE (12) MONTHS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.
ALL APPLICATIONS, RESUMES, LETTERS OF REFERENCE, ETC. SUBMITTED BECOME THE PROPERTY OF THE GLYNN COUNTY BOARD OF COMMISSIONERS AND WILL NOT BE RETURNED. ALL INFORMATION PROVIDED ON THE APPLICATION MAY BE SUBJECT TO PUBLIC DISCLOSURE UNDER THE GEORGIA OPEN RECORDS ACT.
DO NOT SIGN UNTIL YOU READ AND UNDERSTAND THIS STATEMENT.
Date: APPLICANT’S SIGNATURE:
GLYNN COUNTY BOARD OF COMMISSIONERS
HUMAN RESOURCES DEPARTMENT
AUTHORIZATION TO RELEASE INFORMATION ON DRIVING HISTORY
I hereby authorize the Glynn County Board of Commissioners Human Resources Department or other authorized representative of Glynn County Board of Commissioners bearing this release or copy thereof, within twelve (12) months of its date, to obtain any information in my files pertaining to my driving record. This release is executed with full knowledge and understanding that the information is for official use of the Glynn County Board of Commissioners Human Resources Department. Consent is granted for the Glynn County Board of Commissioners to furnish such information as to described above, to third parties in the course of fulfilling its official responsibilities. Should there be any questions as to validity of this release, you may contact me as indicated below.
I hereby authorize my previous employers to provide the Glynn County Board of Commissioners and its agents any and all information that they may request. I hereby release my former employers from liability for providing such information.
Full Name (First, Middle, Maiden, Last)
License Number
Date of Birth
Street Address
City, State, Zip
Signature Date
Notary Signature and Seal Date
GLYNN COUNTY BOARD OF COMMISSIONERS
HUMAN RESOURCES DEPARTMENT
CONSENT TO CHECK CRIMINAL RECORDS
CRIMINAL JUSTICE EMPLOYMENT
I hereby give my consent for the Glynn County Police Department to receive any Georgia or III criminal history record information pertaining to me, as authorized under the state and federal law for individuals seeking employment with a criminal justice agency. This authorization is valid for 12 months from its signature.
Full Name (First, Middle, Maiden, Last)
Street Address
City State Zip Code
Date of Birth Social Security Sex Race
This information is requested for the purpose of employment. It will not be used for any other purpose.
Signature Date
Notary Signature and Seal Date
My Commission Expires
To be completed by Agency only. Do not check.
Special employment provisions (check if applicable): Employment with criminal justice agency – civilian (Purpose code J) Employment with criminal justice agency – P.O.S.T. certified (Purpose code Z)
Contact this candidate