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Rev 2/2012

STATE OF MISSISSIPPI APPLICATION

Return Completed Application to:

Kimbley Hendrix Mississippi Department of Human Services

Division of Procurement Services 200 South Lamar Street Jackson, MS 39201

For Staff/Official Use Only

Received: __________________

Important! Please Read Before you begin the application process:

Applicants must complete and attach the “Supplemental Questions” page when applicable. This page is located on the MSPB website Job Openings screen. Scroll down to the bottom of the screen and click the preferred job; when the description is displayed, click “Print Job Information.” Applications failing to include this page or lacking sufficient information will be returned to the applicant as invalid. Please ensure your application is received by the closing date as indicated on the job posting.

-TYPE OR PRINT IN BLACK INK-

JOB INFORMATION

POSITION #: POSITION TITLE:

PERSONAL INFORMATION

FIRST NAME MIDDLE INITIAL LAST NAME

ADDRESS

CITY STATE ZIP

HOME PHONE ALTERNATE PHONE

MONTH AND DATE OF BIRTH WHICH METHOD DO YOU PREFER TO BE NOTIFIED ABOUT YOUR

APPLICATION STATUS? EMAIL OR PAPER

EMAIL ADDRESS

EDUCATION

WHAT IS YOUR HIGHEST LEVEL OF EDUCATION:

Some High School Some College Associate’s Degree Master’s Degree Doctorate Degree High School Technical College Bachelor’s Degree Specialist’s Degree

HIGH SCHOOL EDUCATION

DID YOU GRADUATE FROM HIGH SCHOOL/RECEIVE A G.E.D.? YES NO

IF NO, WHAT WAS THE HIGHEST GRADE LEVEL COMPLETED? 7 8 9 10 11 12

COLLEGE/UNIVERSITY EDUCATION

SCHOOL NAME DEGREE RECEIVED

DATES ATTENDED

DID YOU GRADUATE?

YES NO

SEMESTER QUARTER

# OF UNITS COMPLETED:

SCHOOL LOCATION (CITY/STATE) MAJOR

SCHOOL NAME DEGREE RECEIVED

DATES ATTENDED

DID YOU GRADUATE?

YES NO

SEMESTER QUARTER

# OF UNITS COMPLETED:

SCHOOL LOCATION (CITY/STATE) MAJOR

SCHOOL NAME DEGREE RECEIVED

DATES ATTENDED

DID YOU GRADUATE?

YES NO

SEMESTER QUARTER

# OF UNITS COMPLETED:

SCHOOL LOCATION (CITY/STATE) MAJOR

Rev 3/2012

CERTIFICATES & LICENSES

TYPE

DATE ISSUED (MONTH/YEAR)

EXPIRATION DATE (MONTH/YEAR)

LICENSE NUMBER

ISSUING AGENCY

SPECIALIZATION

ISSUING AGENCY SPECIALIZATION

ISSUING AGENCY SPECIALIZATION

WORK HISTORY

DATES

From

To

EMPLOYER

POSITION TITLE

ADDRESS, CITY, STATE

PHONE NUMBER

SUPERVISOR (NAME & TITLE)

HOURS PER WEEK

SALARY

MAY WE CONTACT THIS EMPLOYER?

YES NO

DUTIES

WORK HISTORY

AGENCY WIDE QUESTIONS

1. ARE YOU CURRENTLY EMPLOYED WITH THE STATE OF MS? YES NO

2. IF YOU ANSWERED “YES” TO THE PREVIOUS QUESTION, INDICATE WHICH AGENCY AND YOUR CURRENT JOB TITLE. (IF YOU PREVIOUSLY INDICATED

“NO”, PROCEED TO THE NEXT QUESTION.)

(AGENCY NAME) (CURRENT JOB TITLE)

3. HAVE YOU BEEN SEPRATED WITHIN THE LAST 12 MONTHS FROM THE STATE OF MS DUE TO A REDUCTION IN FORCE (RIF)? YES NO

4. IF YOU ANSWERED “YES” TO THE PREVIOUS QUESTION, INDICATE WHICH AGENCY, YOUR PREVIOUS JOB TITLE, AND THE DATE OF YOUR RIF

SEPARATION. (IF YOU PREVIOUSLY INDICATED “NO”, PROCEED TO THE NEXT QUESTION.)

(AGENCY NAME) (PREVIOUS JOB TITLE) (DATE OF RIF)

5. ARE YOU A VETERAN OF THE ARMED FORCES? YES NO

(IF YOU INDICATED “YES”, YOU MUST ATTACH A COPY OF YOUR DD214 OR OTHER PROOF OF SERVICES.)

6. IF YOU ARE A VETERAN, WERE YOU DECLARED DISABLED? YES NO

7. ARE YOU AN ADULT MALE BORN ON OR AFTER JANUARY 1, 1960 WHO REGISTERED FOR SELECTIVE SERVICE BETWEEN THE AGES OF 18 AND 25?

TO MEET THE REQUIREMENTS OF FEDERAL REGULATIONS, MSPB NEEDS TO COLLECT INFORMATION ON THE QUESTIONS BELOW FOR REPORTING PURPOSES ONLY. THIS INFORMATION WILL NOT BE USED FOR MAKING EMPLOYMENT DECISIONS. (OPTIONAL)

8. INDICATE YOUR RACE

AMERICAN INDIAN

WHITE

HISPANIC

BLACK

ASIAN

Other

9. INDICATE YOUR GENDER

MALE

FEMALE

10. AGE GROUP:

UNDER 18

18-25 26-39 40-54 55-69 70+

ADDITIONAL INFORMATION

Additional Information (other schools or training; special qualifications; honors and awards; etc.):

APPLICANT DECLARATIONS

By signing this application, I certify that all statements made herein and on any attached documents are true and complete to the best of my knowledge. I authorize the verification of this information by the Mississippi State Personnel Board and any agency considering me for employment. I know that any misrepresentation herein may lead to rejection of my application, removal of my name from the list of eligibles, and/or dismissal from state service. I understand that, as a condition of employment, I will be required to present documentation which verifies both my identity and my employment eligibility pursuant to federal immigration law.

X_________________________________________________________________ _________________________________________________

SIGNATURE OF APPLICANT DATE

SUPPLEMENTAL QUESTIONS

Applicants must complete and attach the “Supplemental Questions” page when applicable. This page is located on the MSPB website Job Openings screen. Scroll down to the bottom of the screen and click the preferred job; when the description is displayed, click “Print Job Information.” Applications failing to include this page or lacking sufficient information will be returned to the applicant as invalid. Please ensure your application is received by the closing date as indicated on the job posting.

ADDITIONAL WORK HISTORY

JOB INFORMATION

JOB NUMBER: POSITION TITLE:

COLLEGE/UNIVERSITY EDUCATION

SCHOOL NAME DEGREE RECEIVED

DATES ATTENDED DID YOU GRADUATE?

YES NO

SEMESTER QUARTER

# OF UNITS COMPLETED:

SCHOOL LOCATION (CITY/STATE) MAJOR

SCHOOL NAME DEGREE RECEIVED

DATES ATTENDED DID YOU GRADUATE?

YES NO

DATES ATTENDED

SCHOOL LOCATION (CITY/STATE) MAJOR

CERTIFICATES & LICENSES

TYPE DATE ISSUED (MONTH/YEAR) EXPIRATION DATE (MONTH/YEAR)

LICENSE NUMBER ISSUING AGENCY SPECIALIZATION

TYPE DATE ISSUED (MONTH/YEAR) EXPIRATION DATE (MONTH/YEAR)

LICENSE NUMBER ISSUING AGENCY SPECIALIZATION

WORK HISTORY

DATES

From To

EMPLOYER POSITION TITLE

ADDRESS CITY STATE

COMPANY WEBSITE PHONE NUMBER SUPERVISOR (NAME & TITLE)

HOURS WORKED PER WEEK MONTHLY SALARY MAY WE CONTACT THIS EMPLOYER?