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Steps

1. Step One This section is complete This section is incomplete
2. EDUCATION This section is complete This section is incomplete
3. EMPLOYMENT HISTORY Please provide the last 15 years of employment, if applicable. Attach additional sheets if necessary. (From Most Recent) This section is complete This section is incomplete
4. EMPLOYMENT HISTORY Please provide the last 15 years of employment, if applicable. Attach additional sheets if necessary. (From Most Recent) This section is complete This section is incomplete
5. Step Five This section is complete This section is incomplete
6. Disclaimer & Signature This section is complete This section is incomplete
7. Authorization for Release of Infomation This section is complete This section is incomplete
8. Optional Employment Application Supplement This section is complete This section is incomplete

Step One

EMPLOYMENT APPLICATION
Human Resources
603 Watts Avenue Pascagoula, MS 39567
Phone: 228-938-6602 Fax: 228-762-5538 www.cityofpascagoula.com
Date:*
Last Name, First Name*
Position Applying For (1st choice)*
Address/City/State/Zip Code*
Position Applying for (2nd choice)
How did you hear about this Position*
1. City Website
2. Facebook
3. Newspaper
1. Win
2. Other
If other, what source did you hear about this position from?
Home Phone Number
Cell Phone
Email Address
Have you ever worked or attended school under any other name: If so, please list:
Dates Used From:
To:
Upload Your Resume
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EDUCATION

Name of High School and Complete Mailing Address:
Number of Years Completed
Major or Degree
Graduated
1. Yes
2. No
Name of College/University and Complete Mailing Address
Number of Years Completed
Major or Degree
Graduated
1. Yes
2. No
Name of Professional School and Complete Mailing Address
Number of Years Completed
Major or Degree
Graduated
1. Yes
2. No
Other type Education
Number of Years Completed
Major or Degree
Graduated
1. Yes
2. No
List any school/college honors:
List any professional trade, business, or civic activities and offices held. (You may exclude those that indicate race, religion, sex, or national orgin.)
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EMPLOYMENT HISTORY Please provide the last 15 years of employment, if applicable. Attach additional sheets if necessary. (From Most Recent)

Current/Most Recent Employer
Dates of Employment (From - To)
Salary (From - To)
Job Title
Name of Supervisor
May we contact this Employer?
1. Yes
2. No
Complete Address
Phone Number
Reasons for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
Name of Employer
Dates of Employment (From - To)
Salary (From - To)
Job Title
Name of Supervisor
May we contact this Employer?
1. Yes
2. No
Complete Address
Phone Number
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
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EMPLOYMENT HISTORY Please provide the last 15 years of employment, if applicable. Attach additional sheets if necessary. (From Most Recent)

Name of Employer
Dates of Employment (From - To)
Salary (From - To)
Job Title
Name of Supervisor
May we contact tihs Employoer?
1. Yes
2. No
Complete Address
Phone number
Reason for Leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:
Name of Employer
Dates of Employment (From - To)
Salary (From - To)
Job Title
Name of Supervisor
May we contact this Employer?
1. Yes
2. No
Complete Address
Phone Number
Reason for leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:
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Disclaimer & Signature

Certification
The City of Pascagoula is an Equal Opportunity Employer and does not discriminate on the basis of gender, sexual orientation, race, creed, national origin, religion, or handicap.
I certify that all information provided on this application is true, complete, and correct to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification for refusal of employment or in the event of employment, grounds for discharge. I also understand that this application will be kept on file for a period of one (1) year from the date it is received and it is my responsibility to notify Human Resources if any information changes during that time.
In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the City of Pascagoula. The position for which I may be selected shall be evaluated for approximately one (1) year during which period, the position may be abolished or my employment may be terminated at the sole discreation of the City Manager. Notwithstanding the preceding sentence, the term of employment of all employees shall be in accord with all applicable laws, rules, and regulations.
For and in consideration of the acceptance and processing of my application for employment, I agree to hold the City of Pascagoula, its agents, officers and employees harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employ me with the City of Pascagoula. I understand that should information of a serious criminal nature surface as a result of a background investigation, such information may be turned over to the proper authorities.
I understand that if the City of Pascagoula makes a conditional offer of employment, I will be required to undergo a pre-employment physical examination, which includes drug/alcohol screening. I also understand and agree that, if employed I may be requested to submit to a drug/alcohol screening on a routine or neutral selection basis at any time following thirty (30) days after the City of Pascagoula receives the results of such preemployment drug/alcohol tests. I understand that after my employment commences with the City of Pascagoula I may be required to submit to drug/alcohol screening if there is a reasonable suspicion that I have utilized alcohol or controlled substances in a manner profibited by the City of Pascagoula's Employee Drug and Alcohol Testing Policy. I hereby consent to having the results of all drug and/or alcohol screening/testing disclosed to the City of Pascagoula. I also understand that any refusal to consent to such screening/testing is justification for refusal of employment, or in the event of employment, grounds for discharge.
Signature*
Date*
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Authorization for Release of Infomation

To Whom it May Concern: Having made application with the city of Pascagoula for employment and desiring them to be informed of my past record, whether it be financial, academic, military, employment, judicial, criminal, driving or personal reference, I the undersigned, hereby authorize the release of all such information, privileged or otherwise, to the City of Pascagoula and its representatives.
I hereby release all contributing parties of such information from liability or damages that may result from furnishing the information requested, including any liability or damage pursuant to any state or federal laws. I understand my rights under the Title 5, United States Code, Section 552a, the privacy Act of 1974, with regard to access and disclosure of records, and I waive these rights with the understanding that information furnished will be used by the City of Pascagoula in conjunction with employment procedures.
Name:*
Date of Birth:*
Address:*
Home Phone:*
City/State:*
Work Phone:
Zip Code:*
SS Number:
Applicant Signature*
Date:*
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Optional Employment Application Supplement

The City of Pascagoula is committed to a policy of equal employment opportunity. The following information is requested for the Human Resources Office use only in order to assist us in complying with EEO reporting guidelines. Because this information is VOLUNTARY and will NOT be considered for employment purposes, this page will remain separate from your Employment Application. In addition, upon employment, this information will not be used for any subsequent personnel decision.
Name:
Date of Birth:
Address:
Phone Number:
City/State:
Race:
Zip Code:
Sex:
1. Male
1. Female
Veteran Status: Please check one.
1. Non-Veteran
2. Vietnam Era Veteran
1. Disabled Vietnam Era Veteran
2. Veteran-Other
1. Disabled Veteran-Other

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Job Application

Steps

Step One

EDUCATION

EMPLOYMENT HISTORY Please provide the last 15 years of employment, if applicable. Attach additional sheets if necessary. (From Most Recent)

EMPLOYMENT HISTORY Please provide the last 15 years of employment, if applicable. Attach additional sheets if necessary. (From Most Recent)

Step Five

Disclaimer & Signature

Authorization for Release of Infomation

Optional Employment Application Supplement

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