STATECONTRACTOR-APPLICATION-REV-032323.pdf

DEPARTMENT OF MARINE RESOURCES CONTRACT WORKER APPLICATION

Return Completed Application to:

Department of Marine Resources

1141 Bayview Avenue, Suite 101

Biloxi, MS 39530

Attention: Procurement

For Staff/Official Use Only

Received:

-TYPE OR PRINT IN BLACK INK-

JOB INFORMATION

RFA #: 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. OR A HIGH SCHOOL EQUIVALENCY DIPLOMA? 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 9/2018

CERTIFICATES & LICENSES (INCLUDING DRIVER'S LICENSE)

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

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

LICENSE NUMBER ISSUING AGENCY SPECIALIZATION

DATES

From To

WORK HISTORY

EMPLOYER POSITION TITLE

ADDRESS, CITY, STATE

PHONE NUMBER SUPERVISOR (NAME & TITLE)

HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?

YES NO

DUTIES

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

DATES

From To

WORK HISTORY

EMPLOYER POSITION TITLE

ADDRESS, CITY, STATE

PHONE NUMBER SUPERVISOR (NAME & TITLE)

HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?

YES NO

DUTIES

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

MILITARY INFORMATION

1. 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.)

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

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 Department of Marine Resources. I know that any misrepresentation herein may lead to rejection of my application. 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