HCEDA APPLICATION FOR EMPLOYMENT

Hinds County Economic Development Authority

Hinds County Economic Development Authority offers equal employment opportunity for employment to all applicants without regard to race, ethnicity, religion, sex, sexual orientation, national origin, disability, age or military status.

Note: If additional space is needed to respond to any question, please attach additional pages.

PERSONAL INFORMATION

Last*

First*

Middle

Street*

City*

State*

Zip*

Phone No.*

Alternate Phone*

Cell*

Email*

example@example.com

1. Have you ever been discharged or requested to resign from your job? Please explain:*

YesNo

If yes, what job?

Please explain:

2. Are you now being investigated for any alleged misconduct or other alleged grounds for discipline by any governmental body or by a current or previous employer?*

YesNo

If yes, explain and provide the name, address and telephone number of the employer or entity and of the accusation against you:

3. Have you ever been convicted of a misdemeanor (other than a minor traffic violation) or felony?*

YesNo

If yes, please explain:

4. Have you ever been involved in, or are you currently involved in, or do you anticipate involvement in litigation, either as the plaintiff/complainant or defendant/respondent?*

YesNo

If yes, please explain:

5. Have you ever had any license or certificate of any kind revoked or suspended, or have you in any way been sanctioned by, or is any charge or complaint now pending against you before any licensing, certification or other regulatory body, either public or private?*

YesNo

If yes, explain and provide the dates of the proceedings, name, address and telephone number of the agency or body where proceedings took place, a statement of the accusation against you and the final disposition or status of the charge or complaint:

EMPLOYMENT DESIRED

Position*

Date You Can Start*

Date

Salary Desired*

Are you employed now?*

YesNo

If yes, may we inquire of your present employer?

4. Have you ever been involved in, or are you currently involved in, or do you anticipate involvement in litigation, either as the plaintiff/complainant or defendant/respondent?*

YesNo

EDUCATION

High School/GED

Degree Received

Year Graduated

UniversityCollege

Degree Received

Year Graduated

GRADUATE/PROFESSIONAL DEGREES/CERTIFICATIONS

List any graduate or professional degrees you have obtained:

University/College Name and Location of School

Degree Received

Year Graduated

University/College Name and Location of School

Degree Received

Year Graduated

University/College Name and Location of School

Degree Received

Year Graduated

List any related certifications or licenses you have obtained:

Type:

Date Received

Type:

Date Received

FORMER EMPLOYERS

List below your last four employers, starting with the most recent.

Date (Month and Year)

Name and Address of Employer

Contact Telephone

Salary (upon Leaving)

Title

Reason for Leaving

Date (Month and Year)

Name and Address of Employer

Contact Telephone

Salary (upon Leaving)

Title

Reason for Leaving

Date (Month and Year)

Name and Address of Employer

Contact Telephone

Salary (upon Leaving)

Title

Reason for Leaving

Date (Month and Year)

Name and Address of Employer

Contact Telephone

Salary (upon Leaving)

Title

Reason for Leaving

FORMER EMPLOYERS

List below three references who are not related to you and who you have known at least one year.

Name

Address

Position

Years Acquainted

Name

Address

Position

Years Acquainted

Name

Address

Position

Years Acquainted

I certify that the information provided by me in this application is true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire or dismissal if I have been employed, no matter when discovered by the Hinds County Economic Development Authority (Authority

I understand that any employment is conditioned upon a background check. I authorize the Authority to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, and my character and general reputation to the Authority, without giving me prior notice of such disclosure. In addition, I release the Authority, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure.

I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at will" and without a fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Authority. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Authority unless made in writing and approved by the Authority's board of trustees.

I understand that filling out this form does not obligate the Authority to hire me. If hired, I agree to abide by all Authority work rules, bylaws, policies and procedures. The Authority retains the right to revise its policies and procedures, in whole or in part, at any time.

To applicant: If you are hired by the Authority, you will be required to attest to your identity and employment eligibility and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements. You agree to and acknowledge this requirement.

Signature*

Print Name*

Date*

Date

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