1. Print Full Name

First + Middle + Last

Present Residence

Number + Street or Route + City + County + State + Zip Code

How long have you lived at your present residence?

Former Residence

Telephone Numbers

Home + Business + Ext

Social Security No.

2. Have you ever been employed by any local government jurisdiction?

If the answer to this question is yes, please answer the follow-up question below.

If yes to the above question, list jurisdiction?

(Include details of such employment in part 8 of this application)

3. Are you now employed?

If the answer to this question is yes, please answer the follow-up question below.

If yes to the above question, may we refer to your present employer?

4. Do you hold any political or party office?

For RPC use only If yes, resignation will be mandatory at appointment in compliance with state law.

5. Have you ever been convicted of a felony, misdemeanor or any violation of any law, ordinance or police regulation, including traffic violations? (You may exclude any violations for non-moving traffic offenses and any violations which were handled only within the juvenile courts).

Note: the existence of a criminal record does not constitute an automatic bar to employment. The type of conviction and how long ago are important. Give all the facts so that an accurate decision can be made.

If yes, explain fully, what, where, when, and results (i.e. paid fine, served time in jail)

6. Have you ever served in the armed forces or any reserve component of the United States or of any state?

If yes, have you ever received a discharge, release, or separation from such forces which was other than honorable?

If the answer to this question is yes, please answer the follow-up question below.

If yes to the above question, explain fully.

Rank at Time of Separation

Rating

Branch of Service

Employment History

7. Have you ever been discharged or requested to resign from any position?

If the answer to this question is yes, please answer the follow-up question below.

If yes, explain.

8. List and describe all of your paid work experience in military trades or occupations. Be specific. Part of your rating may depend on the information you give below. Start with your present or last position and work back

Last or present job

Start Date

Month + Year

End Date

Month + Year

Hours per week

Starting Salary

$___ per ___

Last Salary

$____ per _____

Immediate Supervisor's Name

Employing Firm

Firm Address

Your Title

Reason for Leaving

Specific Duties

Start Date

Month + Year

End Date

Month + Year

Hours per week

Starting Salary

$___ per ___

Last Salary

$____ per _____

Immediate Supervisor's Name

Employing Firm

Firm Address

Your Title

Reason for Leaving

Specific Duties

Start Date

Month + Year

End Date

Month + Year

Hours per week

Starting Salary

$___ per ___

Last Salary

$____ per _____

Immediate Supervisor's Name

Employing Firm

Firm Address

Your Title

Reason for Leaving

Specific Duties

9. Additional paid work experience continue to work back.

Dates (Month & Year)

From Date + End Date

Hours Per Week

Employing Firm Name and Address

Last Salary (Per Month)

Your Titles and Duties

10. List any volunteer work and all periods of unemployment.

Dates (Month & Year)

From Date + End Date

Hours Per Week

Description of Activities or Volunteer Work

Dates (Month & Year)

From Date + End Date

Hours Per Week

Description of Activities or Volunteer Work

Dates (Month & Year)

From Date + End Date

Hours Per Week

Description of Activities or Volunteer Work

11. Supplementary Information

Are you skilled in any trade or profession?

If the answer to this question is yes, please answer the follow-up question below.

If yes, name.

Do you hold any trade, professional, or other license, certifications or permit?

If the answer to this question is yes, please answer the follow-up question below.

If yes, give title or kind, number, and date of expiration in the space provided below.

Have you ever had a professional license revoked or suspended?

If the answer to the question is yes, please answer the follow-up question below.

If yes, why?

Are you skilled in the operation or maintenance of any office machines, personal computer, computer software, etc.

If the answer to this question is yes, please answer the follow-up question below.

If yes, name the type of computers, software, machines or equipment, and the years of experience you have had, in the space provided below.

Do you hold a current and valid Alabama driver's license?

If the answer to this question is yes, please answer the follow-up question below.

If yes, license #?

Education and Other Formal Training

12. Elementary and High School Education

Highest Grade Completed (Select One)

Do not select 12 unless you have received a diploma from the high school.

Date Last Attended (Month & Year)

Name and Location of Last School

(High School, Junior High, or Elementary)

Are you now working toward a high school diploma?

Do you possess a certificate of high school equivalent (G.E.D.)?

If the answer to this question is yes, please submit the certificate to this office with this application.

13. Colleges and Universities Attended

Name and Location

Dates Attended (Month & Year)

Start Date + End Date

Credit Hours

Semester + Quarter

Degrees Received

Name and Location

Dates Attended (Month & Year)

Start Date + End Date

Credit Hours

Semester + Quarter

Degrees Received

Name and Location

Dates Attended (Month & Year)

Start Date + End Date

Credit Hours

Semester + Quarter

Degrees Received

Chief Undergraduate College Subjects

Credit Hours

Semester + Quarter

Chief Undergraduate College Subjects

Credit Hours

Semester + Quarter

Chief Undergraduate College Subjects

Credit Hours

Semester + Quarter

Chief Graduate College Subjects

Credit Hours

Semester + Quarter

Chief Graduate College Subjects

Credit Hours

Semester + Quarter

Chief Graduate College Subjects

Credit Hours

Semester + Quarter

How many units of CLEP credit are included with your transcript?

Are you now working toward a college degree ( Bachelor's, Graduate, or Special)?

If the answer to this question is yes, please answer the follow-up question below.

If yes, name the diploma or degree and give the date you expect to receive it.

14. Special Training (Correspondence, Business, Trades, Vocational, Armed Forces Schools, Etc.)

Names and Locations of Schools, Training Centers, Institutes, Etc.

Dates Attended (Month & Year)

Start Date + End Date

Courses or Subjects Taken

Certificates Received or Other Pertinent Information

Please read carefully before signing:

I hereby certify that I have never been a member of any organization or group which seeks to alter the form of government of the United States by unconstitutional means. I further certify that all answers to the above questions are true and I understand that any misstatement of material facts contained in this application will cause forfeiture upon my part of all rights to any employment subject to the jurisdiction of The Regional Planning Commission. I understand that this application and all papers in connection with the examination shall be confidential records of The Regional Planning Commission subject to the inspection of the appointing authority as provided by the rules and regulations and to my personal inspection.

Please type your name below for a digital signature.

Employment Application

The Regional Planning Commission of Greater Birmingham

2 Twentieth Street North, Suite 1200 Birmingham, Alabama 35203