Pike County Employment Application

EMPLOYMENT APPLICATION

PIKE COUNTY

P.O. BOX 377

ZEBULON, GA 30295

(770) 567-3406

Serving Citizens Responsibly

A. COUNTY STATUS AS AN EMPLOYER

I understand that Pike County is an "at-will" employer, meaning that the employment relationship may be terminated by either the organization or the employee with or without cause and with or without notice. Nothing set forth herein is intended to grant or convey any contractual or otherwise enforceable right to continued employment or to otherwise

alter or affect Pike County's status as an "at-will" employer.

I understand that the county requires certain information about me to evaluate my qualifications for employment and to conduct its business if I become an employee. I understand that false, incomplete, or misleading statements on this

application may be considered sufficient cause for dismissal, if and when discovered. I understand that the county will

attempt to verify statements on my application and made during the interview.

C. AUTHORIZATION TO RELEASE EMPLOYMENT REFERENCE INFORMATION

I authorize Pike County to contact references and former employers as indicated, and I authorize my previous employers to verify the information on this application and given during the interview process.

D. CONSENT TO PHYSICAL EXAMINATIONS

I consent to a pre-employment physical examination and will, upon request, sign all necessary forms. I understand such physical examination may include medical screening/testing for drug or alcohol abuse. I will sign the medical history release forms necessary so Pike County may complete its background check on my physical condition and suitability

for employment or correct job placement.

E. IAGREE TO SUBMIT TO A DRUG TEST AS REQUIRED.

F. I AGREE TO SUBMIT TO A PRE EMPLOYMENT CRIMINAL HISTORY CHECK.

By signing below, I agree that I have read and understand the policy listed above (Items "A" through "F")

Complete Signature of Applicant*

Date

Position Applying for*

Last Name*

First Name*

Middle Name

Mailbox (or PO Box) Number*

Street name (or 'PO Box')*

City*

State*

Zip Code*

Primary Phone No.*

Alternate Phone No.

EMPLOYMENT RECORD: In the spaces below, give a COMPLETE record of employment. Start with your present or most recent position and work back to your first job. List all jobs you have had since you left school. Explain any periods when you were not employed. If you worked for the same employer but held different jobs, describe each job separately.

Name of Firm*

Dates Employed*

Salary*

Address*

Your Job Title*

Type of Business*

Description of Your Duties*

REASON FOR LEAVING*

Supervisor's Name*

Phone #*

Name of Firm

Dates Employed

Salary

Address

Your Job Title

Type of Business

Description of Your Duties

REASON FOR LEAVING

Supervisor's Name

Phone #

Name of Firm

Dates Employed

Salary

Address

Your Job Title

Type of Business

Description of Your Duties

REASON FOR LEAVING

Supervisor's Name

Phone #

Select Highest Completed Grade

9th Grade10th Grade11th Grade12th Grade

Select Highest Completed Year

Freshman yearSophomore yearJunior yearSenior year (4yr degree)

Post-secondary School Name

Title of Diploma or Degree Achieved

Additional education (Graduate or Trade School) - years completed:

1 year2 years3 years4 years

Describe Post-secondary education (course of study/certificates earned)

Describe Specialized Training, Apprenticeship, skills, and Extracurricular Activities

Honors Received

GED Certificate (skip if not applicable)

Do you have a GED? YesNoIf Yes, is it a Military GED?

State any additional information you feel may be helpful to us in considering your application

List any special skills you may have (i.e. CDL's, Word Processing, Heavy Equipment Operator, Etc.)

Give names of three persons other than relatives or former employers.

Reference #1*

Reference #2*

Reference #3*

US Citizen?*

YesNo

If not, do you possess an Alien Registration Card?

YesNo

If yes, give Alien Registration Number

When would you be available for employment?*

If you are presently employed, may we contact your employer?

YesNo

Do you have any relatives, including elected officials, employed by Pike County?*

YesNo

If yes, list name(s) and the department(s) in which they work

Do you have a valid driver's license?*

YesNo

State of Issue*

License Number*

Class of License

Are you a veteran of the U.S. Military Service?

YesNo

If yes, type of discharge

Do you have a special licenses or certifications that would qualify you for the position you are seeking?

YesNo

If yes, please list

I certify that answers given herein are true and complete to the best of my knowledge. 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 am required to abide by all rules and regulations of the County.

Complete Signature of Applicant*

Date*

Following online submission of this application, please submit a seven year Drivers Summary, available from the State Police Annex, to the Pike County Board of Commissioners @ 331 Thomaston Street, Zebulon, GA 30295.

IMPORTANT: READ A through E below CAREFULLY BEFORE SIGNING

EDUCATION

HIGH SCHOOL

COLLEGE/UNIVERSITY

REFERENCES

AGREEMENT