City of Barwick Application for Employment  PERSONAL INFORMATION:  Full Name: Street Address: City:  First  Middle  Last  Phone:  State:  Zip Code:  Mailing Address (if different):  City: S.S.#:  State:  Zip Code_ State Issue  Driver License:  Exp Date:  POSITION DESIRED: Position:  Expected Salary: YES NO  Have you ever been employed by the City of Barwick:  When:  Are you available to work: Full Time Part Time Do you object to working night shifts: YES  NO  Can you travel if required by position: CRIMINAL HISTORY:  YES  NO  Have you ever been charged, plead guilty or been convicted of an offense in  Municipal and /or City Court? Yes State Court? Yes Federal Court? Yes  No  No No  Please give offense, date, location and disposition of case to all yes answers above (use back of page if more  room is needed:    EDUCATIONAL BACKGROUND: Are you a high school graduate or equivalent? Yes Name and address of school Have you received a college degree? Yes Check degree level: Associate Major/Course of study: Name and address of school: BACKGROUND INVESTIGATION:  No  No Bachelor  The City of Barwick require all employees to submit to a preemployment background investigation Please complete the attached Criminal History Report form, Personal History Release and SF 180(former military personnel only), which will authorize the City of Barwick to receive any background record information  pertaining to you. Yes, lagree to this search  No, id on agree to this search  FORMER MILITARY PERSONNEL:  Branch of Service: Serial Number: Type of Discharge: If yes, please explain:  Date of Service: Rank  Are your currently a member of a Reservice Unit: Yes No  Were you ever the subject of any disciplinary action while a member of the United State Military Yes No  EMPLOYMENT HISTORY:  Please list your last (5) employers (Explain any periods of unemployment):  Employer: Address Job Title: Date of Employment:  Phone Number  Supervisor: Pay Rate:    Employer: Address Job Title: Date of Employment: Employer: Address Job Title: Date of Employment: Employer: Address Job Title: Date of Employment: Explain any YES  Phone Number  Supervisor: Pay Rate:  Phone Number  Supervisor: Pay Rate:  Phone Number  Supervisor: Pay Rate:  Have you ever been involuntarily terminated from any position: YES NO  ADDITIONAL INFORMATION:  Please state any education or training you feel may be helpful to us in considering your application:  Please list any specific skills, qualifications, or achievements you feel ay be helpful to us in considering your  application.  REFERENCE: for at least (5) years. Name:  Please provide at least three (3) reference (not relatives, former or present employers) who have known you    Address: City: Name: Address: City:. Name: Address: City:  State:  Zip Code  State:  Zip Code  State:  Zip Code  lunderstand that the City of Barwick is committed to providing equal opportunity in all equal opportunity in all employment practices, including but not limited to' selection, hiring, promotion, transfer, and compensation to all qualified applicants and employees regardless of age, race, national origin, religion, handicap, disability, or any other category. protected by law. I understand that it is the policy of the City of Barwick to consider all applicants for employed based on their qualifications considering job vacancies. L understand this employment application, or any other City of Barwick documents are not promises of employment. ShouldI I be employedI understand that my employment will be atrial period ofs six months from the date of hiring. Ifurtherunderstand that I am employed I can terminate my employment at any time with or without cause and with or without advance notice and that the City of Barwick has a similar right. lunderstand that no manager or representative of the City of Barwick has any authority to enter into any agreement for employment for any specified period, or to make any agreement contrary to the foregoing. The information given by me in this application is true and completer to the best of my knowledge, I agree that if the information is found to be false, misleading or unsatisfactory in any respect in the City of Barwick judgement thatlwill be disqualified from consideration for  employment or subject to immediate dismissal if discovered afterlhired.  Application Signature  Date.  Thank you for your interest in employment with the City of Barwick    CITY OF BARWICK HUMAN RESOURCE DIVISION CRIMINAL HISTORY REPORT  P.O. Box 146 Barwick, Georgia 317201 Telephone: (229) 735-2311 Fax (229)735-4151  The City of Barwick requires all employees to submit to a Ire-employment criminal history investigation. Please complete this form, which will authorize the City of Barwick to receive any criminal history record information pertaining to you. National, State, and local criminal justice agency records will be included in the criminal  search. Print Full Name: Address: Mailing Address: S.S. Number:  history  Sex:  Race:  DOB:  Driver's License #  State:  Expiration Date:  Applicant Signature  Date  Notary  Date Signed  POLICE DEPARTMENT USE ONLY  Request originally rec'd by: Local records searched by:  Date Rec'd: Date: