Byron - APPLICATION FOR EMPLOYMENT

FOR OFFICE USE ONLY, Date Received

Job Title Applied For

The City of Byron is firmly committed to a policy of Equal Employment Opportunity and does not discriminate against applicants because of race, religion, sex, national origin, disability, age, sexual orientation and genetics.

This application is to be used for employment consideration for all positions with the City of Byron and all of its departments.

I UNDERSTAND THAT MY APPLICATION WILL BE CONSIDERED ACTIVE FOR JOB VACANCIES WHICH OCCUR ONLY DURING THE NEXT SIX (6) MONTHS. IF I WISH TO BE CONSIDERED FOR JOB VACANCIES OCCURING AFTER THAT PERIOD OF TIME, I MUST RENEW MY APPLICATION. IF I WISH TO BE CONSIDERED FOR OTHER JOB TITLES, I MUST APPLY FOR THEM INDIVIDUALLY.

ALL INFORMATION SUBMITTED MAY BE SUBJECT TO PUBLIC REVIEW UNDER THE GEORGIA OPEN RECORDS ACT.

I HAVE READ THE INFORMATION ABOVE AND AGREE.

Name

Date

Signature of Applicant

Job Title Applying For

All Signatures MUST be ORIGINAL Signatures

NOTICE: Your responses must be typewritten or clearly printed in ink. Each question must be answered. If a question does not apply to you, place “N/A” in the blank provided.

Name

First NameLast Name

Social Security Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Cellular Phone

Please enter a valid phone number.

Email

example@example.com

Driver’s License State, Number and Class

Over 18

YesNo

U.S. Citizen

YesNo

List ALL residences for the past five (5)years, beginning with the most recent, including college and/or military residences.*

EDUCATION: List ALL education information beginning with High School.*

Have you ever been suspended, dismissed, demoted or asked to resign from any employment or position you have held?

YesNo

If you answered YES to the above question:

Employer’s Name

Reason:

Have you receivedany traffic violations in the past 3 years?

YesNo

If you answered YES to the above questiondescribe:

Listany additional employment,job-related skills, abilities, training, orexperience that may add to your qualifications for the position that you areapplying for:

Listone (1) previous employment referenceand two (2) other references that are not related to you:

If under 18 years of age, list name, address, and telephone of parent and/orguardian:

I understand that all appointments are probationary for a period of twelve (12) months, during which time I must demonstrate my willingness and ability to perform all of my job functions in order to continue my employment with the City of Byron. I am further aware that willfully witholding information or making false statements on this application will be a basis for denial of a position prior to employment and should such willful withholding or false statements become evident after hiring, such evidence will constitute sufficient grounds for dismissal from employment with the City of Byron. I further understand that if I am selected for employment with the City of Byron, I must comply with any and all provisions of any immigration laws by providing documentary proof of identity and employment authorization prior to commencing work. Any offer of employment is contingent upon all pre-employment conditions being met, including, but not limited to, the City of Byron receiving drug screening, criminal background, and driver history reports. I hereby certify that all statements made by me on this application are true and complete to the best of my knowledge. I authorize the City of Byron to investigate my previous work performance and to confirm any knowledge, skills and abilities required to qualify me for the position I have indicated on this application.

Name

First NameLast Name

Signature of Applicant

Signature of Witness

Date

I Type a label , hereby understand that, as a condition of my employment, I may be subject to drug and/or alcohol testing for any of the following reasons:

I understand that when I am requested to produce a specimen for drug and/or alcohol testing, I must comply immediately. I also understand that a positive drug or alcohol test or that my refusal to produce a specimen upon request can be cause for termination. I further understand that the illegal use, sale, possession or distribution of drugs or alcohol, as well as any illegally obtained prescription medication, is a violation of the City of Byron’s policies and is cause for immediate termination.

I understand and accept the terms of this agreement as a condition of my employment.

Name

First NameLast Name

Date

Signature of Applicant

CRIMINAL HISTORY RECORD INFORMATION/FINGERPRINT SUBMISSION CONSENT FORM

I hereby authorize the City of Byron to receive any Criminal History Record Information pertaining to me which may be in the files of any state of or local criminal justice agency.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date ofBirth

Date

Sex

Race

Social Security

Reason Fingerprinted

Special Employment Provisions (Check if Applicable)

Employment with MentallyDisabled (Purpose Code“M”)Employment with Elder Care (Purpose Code “N”)Employment with Children(Purpose Code “W”)Employment with Criminal JusticeAgency – Non Sworn (PurposeCode “J”)Employment with CriminalJustice Agency – Sworn (PurposeCode “Z”)

This authorization is valid days from date of signature.

90180

I blanksgive consent to the above named to perform periodic criminal history background checks for the duration of my employment with this company.

Signature

Date

Notice to Employers:

If an adverse decision is made concerning employment or licensing against the person whose record was obtained, under the law, the person shall be informed that a record was obtained and the specific contents of the record and the effect the record had upon the decision. Failure to provide this information to the person subject to the adverse decision shall be a misdemeanor.

Results:

Record Attached/ReleasedSearch of therecord of GCIC/NCIC against the applicant shows no criminal history or active warrantsentered into the Criminal JusticeInformation Files, the central repository for all criminalhistory files.

Attested By Byron Police Department

Date

Name (As shown on driver’s license)

Driver’s License Stateand Number

Date of Birth

Date

Job Title

Will you be furnished with a city vehicle?

YesNo

Has your license ever been suspended or restricted?

YesNo

List any accidents or violations that you have had in the past 3 years.

In compliance with Public Law 91-508 (The Fair Credit Reporting Act), as amended by Public Law 104-208 (The Consumer Credit Reporting Reform Act) and applicable State Law, this notice is to inform you that a consumer report, criminal background or motor vehicle report may be obtained in connection with your application for employment with the City of Byron.

I understand that my employment is contingent upon an acceptable driving record that meets the standards of the insurance company and the City of Byron.

If hired, I understand my driving records will be checked periodically for acceptability.

By signing below, I authorize the City of Byron or the City’s insurance company to obtain a consumer report, criminal background or motor vehicle report and provide a copy of same to the City of Byron, if requested.

Notary Public

Signature

My Commission Expires

Date

You must sign the "Authorization to Release Information" form to enable us to contact prior employers, even though we may not contact your present employer.

Date

Signature

AUTHORITY TO RELEASE INFORMATION TO CITY OF BYRON MUNICIPAL GOVERNMENT

To Whom It May Concern:

I hereby authorize representatives of the City of Byron Municipal 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 the request of the bearer.

This release is executed with full knowledge and understanding that the information is for the official use of my firefighter application. Consent is granted for the City of Byron Municipal Government 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 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 of compliance with this authorization and request to release information, or any attempt to comply with it.

Should there be any questions as to the validity of this release, you may contact me at the address indicated below.

I understand that my application will be subject to verification through a comprehensive background investigation.

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 dismiss

Full legal name:

First NameLast Name

Social Security Number:

Phone Number

Please enter a valid phone number.

Social Security Number:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Notary public:

(Must have signature and seal/stamp)

Alcohol and Controlled Substance Testing

As a condition of employment with the City of Byron Municipal Government, you will be required to submit to an alcohol and controlled substance test. Employees must, as a condition of employment and abide by our policies regarding the effects of drug use and the unlawful possession of controlled substances. Employees are expected to report for work without the effects of illegal drugs and alcohol in their bodily systems. Employees must report any conviction under a criminal drug statute for such violations. A report of the conviction must be made within five (5) days after the conviction. The Drug-Free Workplace Act of 1988 mandates this requirement. In order to be employed by the City of Byron Municipal Government, you must successfully pass the aforementioned testing.

By signing this form, I acknowledge the above and consent to such an examination and test.

Date

Signature

Applicant's Certification and Agreement

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I am aware that the falsification of this application or the omission of complete information will result in disqualification, or upon discovery, termination of employment. The City of Byron Municipal Government is hereby authorized to make any investigation of my prior educational and work history. Finally, I agree that all records generated for purposes of employment are property of and shall remain the sole and exclusive property of the City of Byron Municipal Government.

Date

Signature

Resumes, letters of reference, etc. submitted with the application become the property of the City of Byron Municipal Government and will not be returned. The information you have provided on the application is subject to public disclosure under the Georgia Open Records Act.

Applicant's Certification of Employment Eligibility

By my signature below, I certify that I am in compliance with O.C.G.A. 13-10-91 and that I am a citizen, legal permanent resident, or a qualified alien or nonimmigrant and I am eligible to work in the United States.

Date

Signature

ALL OFFICIAL APPLICATIONS MUST CONTAIN ORIGINAL SIGNATURES.

Please verify that you are human*

APPLICATION FOR EMPLOYMENT

EMPLOYEE DRUG AND ALCOHOLSCREEN CONSENT FORM

MOTORVEHICLE RECORD REQUEST