PERSONAL INFORMATION
Last Name:
First Name:
Middle Name:
Social Security Number:       (Without the hyphens)
Home Phone:       Format: 8654445555
Work Phone:       Format: 8654445555
Street Address:
Street Address 2:
City:
State:	(State abbrev. only)
Zip:
Email Address:
Please Enter Position Desired:
If you are applying for more than (1) one position please enter your second choice:
Have you ever applied with Blount County Government before?	Yes or No... YES NO
If yes, when:
Have you ever been employed with Blount County Government?	Yes or No... YES NO
If so, when:
Explain the position and duties:
Do you have a legal right to work in the United States?	Yes or No... YES NO
Are you over the age of 21?	Yes or No... YES NO
Do you have any relatives and/or friends that are employed    by Blount County Government?	Yes or No... YES NO
If Yes, who, and what is the relationship(s)?
Are you interested in a Part-time position?	Yes or No... YES NO
Are you interested in a Full-time position?	Yes or No... YES NO
Are you willing to work shift work including    weekends, holidays, and overtime?	Yes or No... YES NO
What are your salary requirements?	$
Do you consent to the following: polygraph test, comprehensive background investigation, drug test, physical
examination, and psychological evaluation?	Yes or No... YES NO
Have you ever taken a polygraph examination?	Yes or No... YES NO
If Yes, what was the reason for the test?
Examining Orginization:
Are there any incidents in your life that, if known, might disqualify you as an applicant, whether or not you were directly
involved or might be discovered by subsequent investigation?	Yes or No... YES NO
If Yes, Please Explain:
EDUCATION AND TRAINING
Do you have a high school diploma or have passed a GED?	Yes or No... YES NO
If Yes, where did you graduate or recieve your GED?
College/University/Trade or Business School Attended City and State Degree Earned? If So, Type of Degree Major Area(s) of Study
Are you POST/TCI/DCS certified?	Yes or No... YES NO
If Yes, please specify which and in what state:
List other training received such as special courses, work training programs, armed forces training, special qualifications    and skills as licenses, certifications.
List any law enforcement or corrections-related volunteer or reserve service, including the name(s) of the agency(s)    and dates of service.
Based on a review of the job description for the position for which you are applying, are you able to perform the    essential functions of the job?    (Please note that you may later be asked to demonstrate your ability to perform the essential functions.)
Choose One of the following... Yes, but I will need reasonable accommodations in order to perform the essential functions. Yes, and I will not need reasonable accommodations in order to perform the job.
Please describe any accommodations you will need in order to    adequately perform the essential functions of the position:
List three (3) persons, other than relatives or former employers, who have knowledge of your character and/or    abilities.  (Complete mailing address must be listed for application to be considered.)
Name Complete Mailing Address Years Known Phone Number    Format: 8654445555
PRIOR EMPLOYMENT
List below all present and past employment information, beginning with your present or most recent employer, and work backwards. (Please input all dates in the "mm/dd/yyyy" or "mm/yyyy" formats. Example: 01/15/2004  or  01/2004 )
CURRENT OR MOST RECENT EMPLOYER
Name: Address: Phone:   Format: 8654445555 Name of Supervisor: Your Job Title: Brief description of your responsiblites: Date Hired: Date Left (If no longer employed.): Reason(s) for Leaving:  Starting Salary: Current or Last Salary:
Name: Address: Phone:   Format: 8654445555 Name of Supervisor: Your Job Title: Brief description of your responsiblites: Date Hired: Date Left (If no longer employed.): Reason(s) for Leaving:  Starting Salary: Current or Last Salary:
Name: Address: Phone:   Format: 8654445555 Name of Supervisor: Your Job Title: Brief description of your responsiblites: Date Hired: Date Left (If no longer employed.): Reason(s) for Leaving:  Starting Salary: Current or Last Salary:
Name: Address: Phone:   Format: 8654445555 Name of Supervisor: Your Job Title: Brief description of your responsiblites: Date Hired: Date Left (If no longer employed.): Reason(s) for Leaving:  Starting Salary: Current or Last Salary:
Name: Address: Phone:   Format: 8654445555 Name of Supervisor: Your Job Title: Brief description of your responsiblites: Date Hired: Date Left (If no longer employed.): Reason(s) for Leaving:  Starting Salary: Current or Last Salary:
Name: Address: Phone:   Format: 8654445555 Name of Supervisor: Your Job Title: Brief description of your responsiblites: Date Hired: Date Left (If no longer employed.): Reason(s) for Leaving:  Starting Salary: Current or Last Salary:
CRIMINAL AND TRAFFIC INFORMATION
Complete the following for each criminal conviction (felony or misdeamenor, regardless of disposition) if applicable.
Offense: Agency of Occurrence: Date of Occurrence: Classification: Choose One... Misdemenor Felony Disposition (paid fine, plead guilty, found not guilty, found guilty, etc.):
Offense: Agency of Occurrence: Date of Occurrence: Classification: Choose One... Misdemenor Felony Disposition (paid fine, plead guilty, found not guilty, found guilty, etc.):
Offense: Agency of Occurrence: Date of Occurrence: Classification: Choose One... Misdemenor Felony Disposition (paid fine, plead guilty, found not guilty, found guilty, etc.):
Offense: Agency of Occurrence: Date of Occurrence: Classification: Choose One... Misdemenor Felony Disposition (paid fine, plead guilty, found not guilty, found guilty, etc.):
Have you ever been placed on court ordered probation as an    adult?	Yes or No... YES NO
If Yes, please include details (include when, where, why):
Driver's license state:
Driver's license number:
Have you ever been denied issuance of a driver's license, or    have you ever had a driver's license suspended, cancelled or    revoked?	Yes or No... YES NO
If Yes, give date and reason:
Have you ever been involved as a driver in a motor vehicle    accident?	Yes or No... YES NO
If Yes, was a citation issued?	Yes or No... YES NO
If Yes, to whom?
Violation?
Date?    Format: 01/01/2005
Injury or non-injury?	Choose One... Non-Injury Injury
RESIDENCE INFORMATION
Please list all of your residences for the past 10 years, beginning with your current residence and working back.
Address of Residence City, State, and Zip Code Date of Residence From:            To: mm/yyyy - mm/yyyy If rented, give name and address of the person responsible for collecting rent
FINANCIAL INFORMATION
Are you willing to submit to a credit check?	Yes or No... YES NO
Have you ever been subject to a civil suit?	Yes or No... YES NO
If Yes, please give details (include when, where, why):
The amount of indebtedness you may have in itself will not be used in evaluating your qualifications, but rather your behavior exhibited in meeting financial obligations.
MILITARY
Have you ever served in a regular component of the armed    forces?	Yes or No... YES NO
If Yes, what branch of service?
Served From:    Format: 01/2005
Served To:    Format: 01/2005
Duties and skills obtained while serving in the military?
Were you subject to any demotion or other disciplinary action    while in military service?	Yes or No... YES NO
If Yes, please explain:
Please indicate your highest rank, any awards or    commendations, special schools, etc:
Are you a member of the Military Reserves or National Guard?	Yes or No... YES NO
If Yes, which unit and its location:
VOLUNTARY STATISTICAL RECRUITMENT INFORMATION
The information requested on this form will not effect you as an applicant for this position.  This information is collected for compliance with government record keeping and reporting requirements.  The information will be maintained in a confidential file seperate from the employment application and will not be given to anyone who makes hiring decisions.  We would appreciate your cooperation and assistance in our efforts to ensure equal employment opportunity.
Select and mark one of the racial/ethnic categories in which    you wish to be identified:	Choose One... White Black Native American Hispanic Asian Alasken Native Other
If Other, please specify:
Sex:	Choose One... Male Female
Will you need any accommodations or assistance if an    interview is scheduled?	Yes or No... YES NO
Veteran:	Yes or No... YES NO
If you have reviewed your anwsers and are ready to submit your application, please click on the "Submit" button.  (Press the "Submit" button only once, as to not submit your information multiple times)