Northwest Georgia Housing Authority Application for Employment An Equal Opportunity Employer Position Applying For: PERSONAL Name Phone: / (Last) (First) (Middle) Present Address Permanent Mailing SS# Are you a U.S. Citizen? Yes No If not a U.S. Citizen, have you the legal right to remain permanently in the U.S.? Yes No Have you the legal right to work in the U.S.? Yes No Type of Visa Have you ever been convicted of a felony? Yes No If yes, give details: Type of Employment Desired: Full Time Part-Time Date you can start work: Minimum Salary Required: Current Driver s License # State Class Expiration Date: Have you ever had any license, permit or privilege to operate a motor vehicle denied, revoked or suspended? Yes No Have you been involved in an accident in the past three (3) years? Yes No Have you been convicted of violations of motor vehicle laws or ordinances (other than parking) in the past three (3)
years? Yes No EDUCATION Circle last school year completed. Grammar 1 2 3 4 5 6 7 8 High 9 10 11 12 College 13 14 15 16 Graduate 17 18 19 20 Name of high school attended: Graduation date: City/State Name of college attended: Graduation date: City/State Degree, Major If you have a State Certification, complete the following: Certification Number WORK HISTORY Expiration Date List all of your previous positions held within the last ten (10) years. If you do not have enough space, use additional paper. Accuracy of dates, addresses, and phone numbers is essential. 1. Present or Last Employer: May we contact your present employer concerning your employment with them? Yes No 2. Previous Employer 3. Previous Employer
4. Previous Employer REFERENCES 1. 2. 3. Having read the job description for the position for which you are applying, are you in all respects, able to adequately perform the duties as described? Yes No If no, please explain. I understand that any false statement made as a part of this application or any other related form may be considered sufficient cause for withdrawal of a job offer or dismissal from employment at any time. I also grant permission to Northwest Georgia Housing Authority to investigate any and all information and that any after-acquired information that is found to be false may serve as grounds for immediate termination at any time. I hereby release Northwest Georgia Housing Authority and respondents to such investigation from any liability for any damage due to releasing information pertaining hereto. Northwest Georgia Housing Authority, in accordance with applicable Federal and State legislation, does not discriminate on the basis of age, race, religion, color, sex, national origin, disability, veteran status, marital status and/or citizen status. I further understand that in consideration of my employment, I agree to conform to the policies and procedures of Northwest Georgia Housing Authority. I understand and acknowledge that my employment and compensation can be terminated, with or without cause, or without notice by either Northwest Georgia Housing Authority or myself at any time. I understand that no one other than executive administration has any authority to enter into an agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Applicant Signature Date
EEOC / INFORMATION RELEASE Northwest Georgia Housing Authority IS REQUIRED BY THE Equal Employment Opportunity Commission to collect and maintain the information requested below for statistical reporting purposes. It may also be used for identification purposes when requesting information from the sources listed in the Information Release section below. This information will be maintained separately from the application and will not be considered in the application process. Please print neatly. Name: Last First Middle List Previous LAST Names: Social Security #: Date of Birth: / / Sex: Female Male Mo Day Yr Positions applied for: 1. 2. 3. How did you learn about these vacancies? Handicapped / Disabled: Yes No If job accommodations are needed, please specify:. RACIAL / ETHNIC DATA: (Select one) White (Not of Hispanic origin): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East. Black (Not of Hispanic origin): All persons having origins in any of the Black racial groups of Africa. Hispanic All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. Asian or All persons having origins in any of the original peoples of the Far East, Pacific Islander Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, the Philippine Islands, and Samoa. American Indian All persons having origins in any of the original peoples of North America, or Alaskan Native and who maintain cultural identification through tribal affiliation or community recognition. INFORMATION RELEASE: I authorize Northwest Georgia Housing Authority to request information from the following; A. Previous or current employers regarding my work history or other information required by applicable state or federal regulations (such as DOT regulations); B. Any federal, state or local law enforcement agencies or criminal information center regarding my criminal and traffic records; and; C. Educational institutions regarding my education and training (including my GED status). I further certify that the information provided above is correct. Signature: Date:
FLOYD COUNTY, GEORGIA Tim Burkhalter Sheriff OFFICE OF THE SHERIFF Tom Caldwell, IV Chief Deputy I hereby authorize the Floyd County Sheriff s Office to release any and all criminal history record information pertaining to me which may be in the files of any local and/or state criminal justice agency. I do hereby release the Floyd County Sheriff s Office and all personnel from any damages because of/or resulting from furnishing such information. Please indicate below if this Criminal History check is for employment in any of the following areas: Public/Private School, Day Care, Child Welfare, any type of Child Care Mentally Ill and/or Mentally Retarded Nursing home, Personal Care Home or other type of elderly care Criminal Justice Employment General Employment or Housing Please Print Clearly Last Name: First Name: Full Middle Name: Date of Birth: Social Security: Place of Birth: Any Last Name(s) Also Known As: Address: City: State: Sex: Male Female Race: For Official use Only Do Not Write in this Space No Record Found (No Printout Attached) See Attached Record Signature: Date: Agency Signature: Date: USE OF SOCIAL SECURITY NUMBER ON BACKGROUND CHECKS We may ask you to provide us with your social security number as part of the application process. YOU ARE NOT REQUIRED TO DO SO. While you are not required to do so, it may be of help in confirming your identity and expediting your application. Failure to provide your social security number might delay the processing of your background check. It will be used ONLY for the purpose of confirming your identity with the other state, federal, and governmental agencies for data collection. Thanks, Sheriff Tim Burkhalter Not Official Without Seal