Information about http://www.co.pg.md.us/Employment/pgcappl.pdf
PRINCE GEORGE'S COUNTY…
Tags: academic business, address street, announcement number, area code, business general, city state zip, county government, employment application, graduate from high school, home business, largo maryland, location city, mccormick, office of personnel, prince george, rm, six months, social security, state zip code, street city state,Pages: 5
Language: english
Created: Tue Sep 28 09:20:54 1999
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PRINCE GEORGE'S COUNTY GOVERNMENT
THIS BLOCK EMPLOYMENT APPLICATION
FOR OFFICE Office of Personnel
USE ONLY 1400 McCormick Dr. Rm. 159
Largo, Maryland 20774
I.R.C.A. I.D. __Approved __Not Approved
POSITION APPLIED FOR:
ANNOUNCEMENT NUMBER:
__ Authorized __Not Authorized
SOCIAL SECURITY #:
Trkg. #
NAME:
I.R.C.A. Authorization to Work:
PLEASE PRINT LAST FIRST MIDDLE
ADDRESS
STREET
CITY STATE ZIP CODE COUNTY
TELEPHONE: HOME BUSINESS
Supplemental:
Area Code Area Code
Remarks:
N.O.R.:
N.O.T.:
A. Did you graduate from high school, or will Name and location (City and State)
Name:
you graduate within the next six months? of last high school attended
Yes Month/Year No Highest Grade Completed
High school course: Academic Business General Vocational
BY
Do you have a high school equivalency diploma? Yes No
If yes, date received Issuing Agency
SCORE DATE
Credits Completed
B. College or University Major Field Dates Attended Degree Sem. Qtr.
Give name & location of Study From To & Date Hrs. Hrs
ORAL PERFORMANCE
Credits Completed Credits Completed
Sem. Qtr. Sem. Qtr.
Relevant college subjects Hrs. Hrs. Relevant college subjects Hrs. Hrs.
PREFERENCE
TR & EDUC
AVERAGE
WRITTEN
Full-time school? Part-time course?
Other Training (including military schools) Did you finish course? Dates Attended
Give name, location & subject Yes No From To
ALL APPLICANTS PLEASE
FILL IN THE FOLLOWING
INFORMATION
Are you a current Prince George's
County Merit System Employee?
Yes No
If you have worked for Prince
George's County previously,
please enter date of
separation
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
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SKILLS-AVAILABILITY
1. I am interested in: Permanent Temporary
Full-Time Full-Time
Part-Time Part-Time
2. Birth Date Height Weight
(Complete Only for Correctional Officer, Deputy Sheriff and Police Officer)
3. Special qualifications and skills (licenses: skills with machines; patent or inventions; typing or shorthand speed; memberships in professional or
scientific societies, etc.)
4. What is the lowest entrance salary you will accept?
5. If you have a valid driver's license, complete the 6. Will you accept employment anywhere in Prince George's
following: County? Yes No
License No. If not, in what areas will you accept employment?
Issued by (state) 1.
2.
7. In case of emergency please notify: 3.
Name Phone
REFERENCES
8. Do you have any objection to our contacting your present employer? Yes No
If yes, please state the reason
REFERENCES. List three persons who are NOT related to you and who have definite knowledge of your qualifications and fitness for the
position for which you are applying. Do not repeat names of supervisors listed under Work Experience.
FULL NAME PRESENT BUSINESS OR HOME ADDRESS BUSINESS OR OCCUPATION
(Number, Street, City, State and Zip Code)
PREFERENCES
In order to be eligible for veteran's preference, applicants must have been a resident of the State of Maryland for at least the five (5) years preceding
the date of application. Applicants must submit, with the application, a form DD214 and a signed statement listing all places of residence for the past
five (5) years. In addition, applicants seeking preference as a Disabled Veteran must submit, with application, a certificate issued by the Veteran's
Administration showing disability compensation during the past six (6) months. An unmarried widow of a veteran must present proof of marriage,
to, and death of, the veteran.
Check here if you are applying for Veteran's Preference (Forms must be attached).
Some persons may be eligible for preference in employment among eligible applicants under the category of "displaced homemaker". Generally, in
order to qualify, you must meet the following criteria:
1. Be a resident of Maryland for at least five years and currently a resident of Prince George's County.
2. Be 35 years of age or older.
3. Be substantially unemployed for the last five years because of family obligations, and
4. Have recently lost your primary source of income due to separation, divorce, death, or disability of a family member; or lost eligibility in the
Aid for Families with Dependent Children Program.
Check here if you meet all of the above criteria for Displaced Homemaker Preference. If appointed, appropriate proof will be required.
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WORK EXPERIENCE
LIST JOBS STARTING WITH PRESENT AND WORK BACK TO BEGINNING OF EMPLOYMENT
Include your military or merchant marine service in separate blocks in its proper order and describe major duty assignments. Experience acquired
more than 15 years ago may be summarized in one block if it is not applicable to the type of position applied for. Account for periods of
unemployment in separate blocks. In examinations in which experience is a factor, credit will be granted for any civic, welfare, military, religious,
and organizational activity which you have performed either with or without compensation. You may report such experience at the end of your
employment history if you feel that is represents qualifying experience for the position(s) for which you are applying. Show actual time spent in each
activity. Estimate number of hours worked per week in the space provided if you were on part-time work.
A RESUME MAY BE INCLUDED GIVING A MORE DETAILED DESCRIPTION OF WORK PERFORMED OR A LISTING OF
ADDITIONAL JOBS. IF YOU SUBMIT A RESUME TO SUPPLEMENT YOUR WORK HISTORY, YOU MUST STILL ANSWER THE
QUESTIONS ON THIS FORM ABOUT DATES, SALARIES, TITLES AND REASON FOR LEAVING.
PRESENT OR MOST RECENT POSITION: Dates of Employment Last Salary Avg. Hrs.
Month/Year $ per Per Week
Employer Name From To Year
Month Full-Time
Address Part-Time
Supervisor's name and title Telephone
Your title Describe your work:
Reason for Desiring to Leave:
Number and types of positions you supervise(d):
FORMER POSITIONS: Dates of Employment Last Salary Avg. Hrs.
Month/Year $ per Per Week
Employer Name From To Year
Month Full-Time
Address Part-Time
Supervisor's name and title Telephone
Your title Describe your work:
Reason for Desiring to Leave:
Number and types of positions you supervise(d):
FORMER POSITIONS: Dates of Employment Last Salary Avg. Hrs.
Month/Year $ per Per Week
Employer Name From To Year
Month Full-Time
Address Part-Time
Supervisor's name and title Telephone
Your title Describe your work:
Reason for Desiring to Leave:
Number and types of positions you supervise(d):
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USE THIS SPACE FOR ADDITIONAL OR EXPLANATORY INFORMATION
not listed elsewhere on this application. Refer to appropriate item number.
ITEM
NO.:
NOTE: UNDER THE IMMIGRATION CONTROL ACT OF 1986, AN EMPLOYER IS REQUIRED TO HIRE ONLY U.S. CITIZENS AND
LAWFULLY AUTHORIZED ALIEN WORKERS. APPLICANTS WHO ARE SELECTED FOR EMPLOYMENT WILL BE
REQUIRED TO SHOW AND VERIFY AUTHORIZATION TO WORK IN THE UNITED STATES.
9. Have you ever been convicted of a felony? Yes No
If you answer "Yes", give details in space provided above showing (1) Date; (2) Charge; (3) Place (4) Court; and (5) Action Taken;
NOTE: Convictions or discharges do not necessarily disqualify you from employment. Each case will be considered fairly on its merits and
after full consideration of the applicant's views.
10. Within the last five years, have you been fired for any reason? Yes No
11. Within the last five years, have you quit a job after being notified that you would be fired? Yes No
If "Yes", give details in space provided above.
The following notice applies to everyone except applicants for law enforcement officer positions as defined by Article 27, Section 727, or
any employee of the any enforcement agency of the State of Maryland, or any county, incorporated city or town, or other municipal corporation.
"UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQUIRE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR
PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO OR TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR
TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. ANY EMPLOYER WHO
VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT TO EXCEED $100.00."
I hereby acknowledge that I have read and I understand the polygraph notice written above. I also hereby affirm that this application contains
no willful misrepresentations or falsifications and that the information contained herein is true and accurate to the best of my knowledge. I
understand that should investigation at any time disclose any misrepresentation or falsification of information contained in this document, my
application will be disapproved and my name removed from any further consideration for employment. I also understand that should I be
offered employment and accept a position with Prince George's County and it is subsequently discovered that the information provided herein is
false, I may be terminated from employment pursuant to Section 16-193(c)(1)(i)(4) of the Personnel Law of Prince George's County.
Date Signed: Signature:
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PRINCE GEORGE'S COUNTY GOVERNMENT
TRACKING FORM
Please type or print.
Announcement Number Social Security Number Office Use Only
Code Date
Name:
Last First Middle
Street:
City: State Zip
Home Telephone Work Telephone
PLEASE NOTE: The following information is used for statistical and record keeping purposes only. This information is voluntary/confidential and
will not subject applicant to adverse treatment.
Sex (check one) Race (check one) Date of Birth
M Male W White (Caucasian) B African American
F Female M Native American O Asian or Pacific Islanders
S Hispanic (including persons of Mexican, Puerto Rican, Cuban or other Spanish origin)
Residence (check one)
A Prince George's County E Howard County I Arlington County
B Charles County F Montgomery County J Fairfax County
C Calvert County G St. Mary's County K Fairfax City
D Anne Arundel County H District of Columbia L Alexandria
M Other (specify)
THE PRINCE GEORGE'S COUNTY GOVERNMENT
This acknowledges receipt of your application for the position of
with the Prince George's County Government.
THANK YOU
Name
Street
City State Zip
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