Application for Employment - HCHRA



Application for EmploymentEnter Last Four Digits of Social Security Number Below 25336513398500GENERAL INSTRUCTIONS: A separate application is required for each job. All questions MUST be answered for this application to be reviewed.Hinds County Human Resource Agency (HCHRA)258 Maddox Road, P. O. Box 22657, Jackson, Mississippi 39225-2657AN EQUAL OPPORTUNITY EMPLOYERPosition Applied For Date of ApplicationClick here to enter a date.Referral Source: ?Advertisement ?Employee?Relative?Government Employment Agency?Private Employment Agency ?Other Name of Source (If Applicable) Name LastFirstMiddleAddress StreetApt. NoCityStateZip CodeTelephone Number( ) If necessary, best time to call you at home: ?a.m. ?p.m.May we contact you at work? …………………………………………………………?Yes?NoIf yes, work number ……… & best time to call: ?a.m. ?p.m.Have you ever been employed at HCHRA before? ………………………………………?Yes?NoIf yes, give dates …………………………..From To Date available for work …………………………………………………..…. Type of employment desired …………………………?Full-Time ?Part-Time ?Temporary Are you on lay-off and subject to recall? ………………………………………………. ?Yes?NoWill you travel if job requires it? ………………………………………………………… ?Yes?NoWill you work overtime if required? ................................................................................... ?Yes?NoAre you able to meet the attendance requirements of this position? ……………………… ?Yes?NoDo you have a valid Mississippi Commercial Driver’s License? ………………………… ?Yes?NoIf yes, Driver’s License Number Endorsement(s) Employment History-19058064500List your last four (4) employers, assignments, or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below.-19056159500EmployerTelephoneDates EmployedSummarize the nature of the work performed and job responsibilities. From To Address Job Title Hourly Rate/Salary StartingImmediate Supervisor and Title $ Per Choose an item.Reason for Leaving Hourly Rate/SalaryFinalMay we contact for reference??Yes?No?Later$ Per Choose an item. EmployerTelephoneDates EmployedSummarize the nature of the work performed and job responsibilities. From To Address Job Title Hourly Rate/Salary StartingImmediate Supervisor and Title $ Per Choose an item.Reason for Leaving Hourly Rate/SalaryFinalMay we contact for reference??Yes?No?Later$ Per Choose an item.EmployerTelephoneDates EmployedSummarize the nature of the work performed and job responsibilities. From To Address Job Title Hourly Rate/Salary StartingImmediate Supervisor and Title $ Per Choose an item.Reason for Leaving Hourly Rate/SalaryFinalMay we contact for reference??Yes?No?Later$ Per Choose an item.EmployerTelephoneDates EmployedSummarize the nature of the work performed and job responsibilities. From To Address Job Title Hourly Rate/Salary StartingImmediate Supervisor and Title $ Per Choose an item.Reason for Leaving Hourly Rate/SalaryFinalMay we contact for reference??Yes?No?Later$ Per Choose an ments (including explanation of any gaps in employment) Skills and Qualifications-6858011557000Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for this position with HCHRA. -685802032000 Educational BackgroundA. List last three (3) schools attended, starting with the last one. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade Point Average or Class Rank, and E. Major and minor field of study, if applicable.A. SchoolB. No. Years Completed C. Degree /DiplomaD. GPAD. Class RankE. MajorE. Minor Choose an item.Choose an item. Choose an item.Choose an item. Choose an item.Choose an item. Choose an item.Choose an item. Additional Information-6858011557000List any additional information you would like us to consider. -685802032000 Certification StatementI hereby certify, under penalty of perjury, that all statements on this application are true, correct, and complete. I further agree and understand that any misrepresentation by me in this application will be sufficient cause for this application to be forfeited and/or separation from Hinds County Human Resource Agency’s (HCHRA) service if I have been employed. I authorize HCHRA to investigate all references and to secure additional information about me, if job related. I hereby release from liability HCHRA and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.HCHRA is an Equal Opportunity Employer. HCHRA does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.I understand that this application will remain active for six months from the date of application. At the conclusion of this time, if I have not heard from HCHRA and still wish to be considered for employment, it will be necessary for me to complete a new application. I further understand and agree that if employed, I may resign at any time and HCHRA reserves the right to terminate my employment at any time, with or without cause, and without prior notice. I also understand that no representative of HCHRA has the authority to make any assurances to the contrary.Signature of Applicant DateClick here to enter a date. HCHRA--AFE.Word Pages(3)—Rev08/10 ................
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