CITY OF GRANTVILLE  Gran  1  ince 1B3V  APPLICATION FOR EMPLOYMENT  POSITION APPLIED FOR:  All information provided on this application MUST BE COMPLETE so that all applications can be given equitable consideration. All qualified applicants will receive consideration for employment regardless of race, color, religion, sex, age, national origin or disability. City of Grantville will hire only authorized workers, regardless of national origin. This application must be typed or printed. Please complete one application for each position for which you are applying. YOU MUST SIGN AND DATE YOUR APPLICATION IN INK. RESUMES ARE NOT  ACCEPTED INI LIEUOF A COMPLETED: APPLICATION.  INCOMPLETE APPLICATIONS MAY BE REJECTED  PERSONAL DATA  Last Name Address: Telephone:  First  Middle  Street Home Phone#  Apt#  City Work Phone#  State  ZipCode  Celll Phone # Date Available to begin: Weekend?  How did youl hear oft this opening? WILL YOU. ACCEPT: Temporary Work? Are you over 18 years old? employment in the United States Have you ever worked for us before? No  Part Time Work?  Are you eligible to work in the United Stated either because you: are al U.S. citizen  or have U.S. government approval to dos so? No Yes  NOTE: If offered employment you will be required to provide documentation to verify employment eligibility. Failure to provide the requested documentation may result in a determination that the applicant is ineligible for  Yes  Ifyes, When?.  I    Give name, relationship, & department ofa any relatives who are employed by the City of Grantville:  In Case of an emergency: Please list your closest living relative:  Name Address Phone number Additional contact person: Name Address Phone Number  DRIVER'S HISTORY INFORMATION: Do you have a valid Drivers License? No Yes  Licenset dates:  Class  State_  Have you received any traffic violations int thej past three years? No Yes  Ifyes, listt type of offense and  CRIMINAL HISTORY INFORMATION:  Have you ever been convicted of or plead guilty or no contest to a misdemeanor? (For example: DUI, Bad Checks, adjudicated in Juvenile Court or under a Youth Offender Law). If yes, describe the circumstances: (Date, Place,  etc.) NO_ YES  (Omit non-moving traffic violations/parking tickets and any offense which was finally  Charges, and Disposition). Use additional sheets ifr necessary.  Have you ever been convicted of or plead guilty or no contest to a felony? NO_ YES the circumstances: (Date, Place, Charges, and Disposition). Use additional sheets if necessary.  If yes, describe  NOTE: An applicant convicted ofa criminal offense involving the manufacture, distribution, trafficking, or sale ofa controlled substance, dangerous drugs or marijuana, or convicted of any felony involving a violent crime such as assault with a deadly weapon, aggravated assault or murder are ineligible for employment with the City of Grantville. Such applicant shall be automatically rejected, Applicants convicted of any other felony will be Have you ever been suspended, demoted, dismissed or asked to resign from any job?) No Yes_  considered on a case-by-case basis. Ifyes, explain in detail:  2    EDUCATION  High School Name  Address:  (Name ofhigh school or state authority issuing the diploma or certificate)  Circle highest grade completed: 7 8 9 10 11 12 Ifnot a high school graduate, do youl have a GED? No Yes  Graduated? No Yes  Colleges/Umiyersities  Please complete the following section forj post-secondary education (Technical hoClegeynvenite:  Name of School  City  State  IfNol Degree, Hours Earned  Major Type of Degree Degree  Earned yes/no  Describe any specialize training, qualifications, apprenticeship, skills, and extra-curricular activities which relate to the job for which you: are: applying. Include office equipment, computer skills, foreign language skills, typing skills, and business equipment or machine operating skills, which may relate to the position for which you are applying. Use  additional sheets if necessary.  REFERENCES - Give names, addresses, and telephone numbers of three references that ARE NOT related to you  and ARE NOT previous employers.  1. Name Address: Street 2. Name Address: Street  Phone# Zip  Apt#  City  State  Phone# Zip  Apt#  City  State  3. Name Address: Street  Phone# Zip  Apt#  City 3  State    WORK HISTORY  Describe your work history beginning with you current or most recent job. Include military and volunteer experience and periods ofu unemployment. Failure to give complete information regarding each jobl held may result in your disqualifications. Complete addresses with zip codes and telephone numbers for all employers Aresume may be attached only as additional information and will not be accepted in lieu of completing  are necessary.  this section. Use additional sheets if necessary. Name of Organization or Firm:  Telephone:  Address: Street City Name of Your Supervisor: Your Official Job Title: Specific Reason forl Leaving: Describe Your Specific Job Duties:  Dates Employed: From Mo/Yr Pay Start:  State  Zip Code  Tol Mo/Yr End:  Name ofC Organization orl Firm:  Telephone:  Address: Street City Name of Your Supervisor: Your Official Job Title: Specific Reason forl Leaving: Describe Your Specific. Jobl Duties:  Dates Employed: From Mo/Yr Pay Start:  State  Zip Code  ToN Mo/Yr End:  4    Name of Organization or Firm:  Telephone:  Address: Street City Name of Your Supervisor: Your Official Job Title: Specific Reason for Leaving: Describe Your Specific Job Duties:  Dates Employed: From Mo/Yr Pay Start:  State  Zip Code  Tol Mo/Yr End:  Name ofOrganization or Firm:  Telephone:  Address: Street City Name of Your Supervisor: Your Official Job Title: Specific Reason for Leaving: Describe Your Specific. Jobl Duties:  Dates Employed: From Mo/Yr  State  Zip Code  Tol Mo/Yr  Pay Start:  End:  Please use this space for additional information pertinent to your education, training, and experience:  5    Applicant's Certification and Agreement  Icertify 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 Grantville is hereby authorized to make any investigation of my prior education 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 ofthe City of Grantville.  Date:  Applicant's Signature:  Resumes, letters of reference, etc. submitted with the application become the City of Grantville and will not be returned. The information you have provided on the application  iss subject to public disclosure under the Georgia Open Record Act.  ALL OFFICIAL APPLICATIONS MUST CONTAIN ORIGINAL SIGNATURES.  6    THE CITY OF GRANTVILLE  AUTHORIZATION TO RELEASE INFORMATION FORM  The intent of this authorization is to give my ongoing consent for full and complete disclosure of but not limited to my hospital records, court records, police records including juvenile reports; medical records; background investigative material and records; military records; current and former employment records; educational records and transcripts, etc.; arrest records; and any other records  discovered by reference. I,. Last Name  First Name Height Race  Middle  Social Security Number Date of Birth  Weight Sex City  Eye Color Hair Color  Street Address Authorize: City ofGrantville  State  Zip Code  123 LaGrange Street Grantville, GA 30220 (770)5 583-2289  to1 receive my criminal history record from the Grantville Police Department and/or Coweta County Sheriff's Office/ Corrections Department NCIS/GCIC database search. I understand the request will only be used for  employment purposes.  Signature  Notice: unless all blanks are completed ont this form and the formi is notarized noi information willl be released.  Sworn' To And Subscribed Before Me  This Notary Public  Day of  20  7    THE CITY OF GRANTVILLE HUMAN RESOURCES DEPARTMENT AUTHORIZATION TO OBTAIN MOTOR VEHICLE RECORD Lu understand that driving a City of Grantville vehicle (or my own, vehicle, as required) is a requirement of the positionIam being considered for and that having and maintaining a satisfactory driving record is a condition of my employment. Ihereby authorize the City of Grantville, within twelve months ofthis date, to obtain any information in my files pertaining to my driving record for This release is executed will full knowledge and understand that the information is for official use of the City of Grantville for purposes of employment or underwriting of insurance and will not be Consent is granted for the City of Grantville to furnish such information as described above to third  the period indicated below.  used for any other purpose.  parties int the course of fulfilling its official responsibilities.  Full Name: Date of Birth: Signature: This Notary Public: Notary Expiration:  Male Female_ State Issued: Seven  (Print) Driver's License Number:  Driver's License Expiration Date:  Request: Three-year  Date:  Sworn to and Subscribed Before Me:  Day of_  20  8    Name-Based Criminal History Record Information Consent/Inquiry Form  Ihereby authorize,  too conduct ani inquiry for  Agency/Company  the purpose listed below and receive any Georgia and/or national criminal history record information  as authorized by state and federal law.  Full Name (print) Address Sex  Race  Date of Birth  Social Security Number  This authorization is valid for  days from date of signature.  give consent to the above-named  entity to perform periodic criminal history background checks fort the duration of my employment.  Signature  Date Date  Attorney for Individual (Pur E and U Only)  Bar Number  Date ofl Inquiry:  Time of Inquiry:  Operator's Initials:  Purpose Code Used: (check one) E-E Employment M-1 Working with Mentally Disabled N-Working with Elderly W-V Working with Children P-P Public Records (no consent required) U-P Personal Copy  NON-CRIMINALJUSTICEPURPOSES  PERSONAL REQUEST OVCUACAPERATONNT  CRIMINALJUSTICEEMPLOYMENT  J-C Civilian Criminal. Justice Employment (State & III Info Received) Z-S Sworn Criminal. Justice Employment (State & II Info Received)  The inquiry resulted in thei following: (check all that apply) No Criminal Record Available Criminal Record Attached/Released) No NCIC/GCIC Warrant Wanting Agency Name: Wanting Agency Telephone: Agency Designee Signature and' Title  Possible NCIC/GCICI Warrant (List Wanting Agency Below)  Revised March: 2019