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City of Natchez Civil Service Application (Police Officer or Firefighter)

2. Position Applied For:*
   -- Select One --Probationary Police OfficerProbationary FirefighterBoth Probationary Police Officer and Firefighter

   Specify which test you are applying for. If you're interested in taking both, list both as job applying for.

4. First Name*

5. Last Name*

7. Address*

9. E-Mail Address

11. City*

12. State*

13. Zip*

15. Phone Number: *

16. Alternate Phone Number:

18. HAVE YOU EVER BEEN EMPLOYED WITH THE CITY OF NATCHEZ?*

    1. YES
    2. NO

19. IF YES, WHAT DEPARTMENT/POSITION?

21. DO YOU LIVE IN ADAMS COUNTY?*

    1. YES
    2. NO

22. IF YES, HOW LONG HAVE YOU RESIDED IN ADAMS COUNTY?

24. HAVE YOU EVER TAKEN A CIVIL SERVICE TEST(Police or Fire)?*

    1. YES
    2. NO

25. IF YES, WHICH EXAM?

    1. PROBATIONARY POLICE
    2. PROBATIONARY FIREFIGHTER

26. IF YES, WHAT YEAR?
    -- Select One --200020012002200320042005200620072008200920102011201220132014201520162017

28. ARE YOU PREPARED TO SUBMIT ALL OF THE FOLLOWING REQUIRED DOCUMENTS TO THE PERSONNEL OFFICE?*

    Driver's License, Social Security Card, Birth Certificate, High School Diploma, TWO Copies of High School AND College Transcripts, and Any Training Certificates

    1. YES
    2. NO
29. DO YOU UNDERSTAND THAT YOU WILL BE REQUIRED TO PASS AN APPROPRIATE MEDICAL AND PHYSICAL EXAMINATION, DRUG SCREENING, AND PSYCHOLOGICAL PROFILE IF SELECTED FOR APPOINTMENT AND THAT FAILURE TO PASS WILL DISQUALIFY YOU?*

    1. YES
    2. NO

31. ELEMENTARY SCHOOL?*

32. HOW MANY YEARS DID YOU COMPLETE?*

34. HIGH SCHOOL?*

35. WHAT WAS YOUR COURSE OF STUDY?

36. HOW MANY YEARS DID YOU COMPLETE?*

37. NAME DIPLOMA OR DEGREE RECEIVED AND WHAT YEAR IT WAS COMPLETED

39. DID YOU ATTEND COLLEGE?*

    1. YES
    2. NO

40. WHAT WAS YOUR COURSE OF STUDY?

41. HOW MANY YEARS DID YOU COMPLETE?

42. NAME DIPLOMA OR DEGREE RECEIVED AND WHAT YEAR IT WAS COMPLETED

44. PROFFESIONAL/VO-TECH?

45. WHAT WAS YOUR COURSE OF STUDY?

46. HOW MANY YEARS DID YOU COMPLETE?

47. NAME DIPLOMA OR DEGREE RECEIVED AND WHAT YEAR IT WAS COMPLETED

49. PREVIOUS EMPLOYER:

50. TELEPHONE:

52. ADDRESS:

54. CITY:

55. STATE:

56. ZIP CODE:

58. POSITION HELD:

59. DATES EMPLOYED:

61. BEGINNING SALARY:

62. ENDING SALARY:

64. REASON FOR LEAVING:

66. PREVIOUS EMPLOYER:

67. TELEPHONE:

69. ADDRESS:

71. CITY:

72. STATE:

73. ZIP CODE:

75. POSITION HELD:

76. DATES EMPLOYED:

78. BEGINNING SALARY:

79. ENDING SALARY:

81. REASON FOR LEAVING:

83. PREVIOUS EMPLOYER:

84. TELEPHONE:

86. ADDRESS:

88. CITY:

89. STATE:

90. ZIP CODE:

92. POSITION HELD:

93. DATES EMPLOYED:

95. MAY WE REFER TO YOUR PRESENT EMPLOYER?*

    1. YES
    2. NO
    3. N/A

97. LIST ANY SKILLS, KNOWLEDGE, TRADE, SPECIAL TRAINING, APPRENTICESHIP EXPERIENCE OR JOB RELATED ACTIVITIES YOU HAVE ACQUIRED:

99. HAVE YOU EVER BEEN CONVICTED OF A CRIME, EXCLUDING MISDEMEANORS AND MINOR TRAFFIC VIOLATIONS?*

    1. YES
    2. NO

100. IF YES, EXPLAIN:

102. HAVE YOU EVER SERVED IN THE ARMED SERVICES?*

     1. YES
     2. NO

103. IF YES, WHAT BRANCH?

104. DATES OF DUTY:

106. WHAT WERE YOUR DUTIES IN THE SERVICE (INCLUDE SPECIAL TRAINING)?

108. ARE YOU RELATED BY BLOOD OR MARRIAGE TO ANY OFFICERS OR EMPLOYEES OF THE CITY OF NATCHEZ?*

     1. YES
     2. NO

109. IF YES, LIST THEIR NAME, RELATIONSHIP, AND POSITION OF EMPLOYMENT:

111. HAVE YOU HELD ANY ELECTED OR APPOINTED OFFICE?*

     1. YES
     2. NO

112. IF SO, STATE TITLE OF POSITION AND DATE OF ELECTION OR APPOINTMENT:

114. List below your residence for the last five years:

116. Address1

118. City

119. State

120. Zip

122. Address1

124. City

125. State

126. Zip

128. Address1

130. City

131. State

132. Zip

134. Address1

136. City

137. State

138. Zip

140. Address1

142. City

143. State

144. Zip

146. PERSONAL REFERENCES:
     List name, addresses, and telephone of three persons as personal references. (Do NOT List Relatives)

     List name, addresses, and telephone of three persons as personal references. (Do NOT List Relatives)

148. Name

149. Phone Number:

151. Name

152. Phone Number:

154. Name

155. Phone Number:

157. I hereby certify that this application contains no willful misrepresentation or falsifications and that the information given by me is true and complete to the best of my knowledge. I understand that any deliberate or withholding of material facts, written or verbal, will subject me to disqualification from employment or dismissal from the City of Natchez. I agree that the City or its agents may thoroughly investigate and inquire into and examine any record concerning criminal, employment, and/or school records. My signature is my authorization for the City to conduct the aforementioned investigations as well as any drug test policy that may be in place.

159. SIGNATURE*

161. Pre-Employment Drug Testing Consent Form
     As a condition for my application being considered, I understand and agree to submit to a urine drug test for illegal substances. I recognize that in no way shall this test be used to screen out individuals taking legal medications. I understand that if my test results are positive for illegal substances, I shall not be considered further by the City of Natchez for employment. I hereby authorize any certified medical facility to conduct such testing and to provide the results to the City of Natchez. I release the City of Natchez from ALL liability which may arise or result from the aforementioned drug test.

     As a condition for my application being considered, I understand and agree to submit to a urine drug test for illegal substances. I recognize that in no way shall this test be used to screen out individuals taking legal medications. I understand that if my test results are positive for illegal substances, I shall not be considered further by the City of Natchez for employment. I hereby authorize any certified medical facility to conduct such testing and to provide the results to the City of Natchez. I release the City of Natchez from ALL liability which may arise or result from the aforementioned drug test.

163. SIGNATURE*

165. Applicant Authorization for Reference Check
     I voluntarily consent to authorize the City of Natchez or any of its officers, employees, or agents to check my references by contacting any person or entity whom they deem to be an appropriate reference. I understand that questions may be asked about my educational background, work experience, achievements, wage history, performance, attendance, personal history, character, personality, disciplinary information, and reason for separation from former employment. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment with the City of Natchez. I also hereby release the City of Natchez from all liability for damages or claims - including, but not limited to, defamation, interference with contract, and negligence - which may arise or result from any reference information gathered pursuant to this authorization.

     I voluntarily consent to authorize the City of Natchez or any of its officers, employees, or agents to check my references by contacting any person or entity whom they deem to be an appropriate reference. I understand that questions may be asked about my educational background, work experience, achievements, wage history, performance, attendance, personal history, character, personality, disciplinary information, and reason for separation from former employment. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment with the City of Natchez. I also hereby release the City of Natchez from all liability for damages or claims - including, but not limited to, defamation, interference with contract, and negligence - which may arise or result from any reference information gathered pursuant to this authorization.

167. SIGNATURE*

169. Personal Inquiry Waiver Authority for Release of Information
     I respectfully request and authorize you to furnish the City of Natchez/Civil Service Commission any and all information that you may have concerning my work record, military record, reputation, and criminal background. This information is to be used to assist the City in determining my qualifications and fitness for the position for which I am seeking with the City of Natchez. I hereby release you, your organization and others from liability or damage which may result from furnishing the information requested above.

     I respectfully request and authorize you to furnish the City of Natchez/Civil Service Commission any and all information that you may have concerning my work record, military record, reputation, and criminal background. This information is to be used to assist the City in determining my qualifications and fitness for the position for which I am seeking with the City of Natchez. I hereby release you, your organization and others from liability or damage which may result from furnishing the information requested above.

171. First Name*

172. Last Name*

174. Address1*

176. City*

177. State*

178. Zip*

180. SIGNATURE*

182. ELECTRONIC SIGNATURE AGREEMENT:*

     By signing this Electronic Signature Acknowledgment, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

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

     This field is not part of the form submission.

185. Submit

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