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1 APPLICATION FOR EMPLOYMENT 312 Highway 90 Bay Saint Louis, Mississippi (228) The Hancock County Library System is an Equal Employment Opportunity and does not discriminate due to race, color, religion, age, sex, or national origin. Please Print Position Applied for: Date of Application: How did you find out about this opening? Last Name First Name Middle Name City State Zip Code Home Telephone Number Social Security Number (voluntary) Mobile Telephone Number Best time to contact you at home is: AM / PM If you are under 18 years of age, can you provide required proof of your eligibility to work? Have you ever filed an application with the Hancock County Library System? If yes, give date: Have you ever been employed with the Hancock County Library System? If yes, give date: Do any of your friends or relatives work with the Hancock County Library System? If yes, state name, relationship, and location: Are you currently employed? May we contact your employer? Date available for work: / / What is your desired salary range? Are you available to work: Full Time Part Time (Please indicate Mornings Afternoon Evenings) Temporary (Please indicate dates available to ) Can you travel if the job requires it?

2 Education Level Name/ of School Course of Study. Yrs. Completed Did You Graduate? Type Degree/Date High School/ GED Undergraduate College or University Graduate/ Professional Other How many UNDERGRADUATE semester hours/credits in LIBRARY SCIENCE do you have? How many GRADUATE semester hours/credits in LIBRARY SCIENCE do you have? Do you have any specialized certifications? Professional Memberships List all current professional organization memberships below: Professional References (Do not include family, friends, or present or former immediate supervisors.) Name and Occupation Phone Number Special Skills and Abilities What experience do you have with computers and/or automated library systems (identify hardware and software used)? What are your reading interests, special skills, talents, etc.? Name at least 3 books or 3 magazines you have read in the past year?

3 Experience Resumes are not accepted as a substitute for completion of this section Start with your present or most recent position and work back. Answer all items for each position, including starting/ending salaries. Account for all periods of unemployment exceeding three (3) months since beginning your professional career. If more space is needed, you may attach an additional sheet. /Present Job Title Reason for Leaving May we contact? /Present Job Title Reason for Leaving May we contact? /Present Job Title Reason for Leaving May we contact? Comments: Include explanation of any gaps in employment.

4 Incomplete and/or unsigned applications will be returned to the applicant. Read and sign below I certify that all the foregoing statements are complete, true and correct to the best of my knowledge and belief. In consideration of the employment sought, I hereby authorize the Hancock County Library System to make an investigation and request former employers to furnish any information concerning me, and I release them from any and all liabilities or damages because of furnishing such information. In the event of employment, I understand that misrepresentation of information given in my application and/or interview may subject me to disqualification for competition for any job or to termination of employment if employed by the Library System. I understand, also, that I am required to abide by all the policies, procedures and standards of conduct of the Hancock County Library System. Signature of Applicant Date Have you enclosed other documents (resume, etc.) as requested? FOR HANCOCK COUNTY LIBRARY USE ONLY Interviewed by: Date: Date: Job Title: Rate of Pay: Department/Branch Location: Revised

5 Reference Check Claim - Waiver Form the prospective employee: Please read this document carefully. If you agree to the statements, terms, and conditions set forth herein, please initial each paragraph where indicated, and sign and date the form at the bottom. A. Verification Of Accuracy Of Statements Made In Employment Application: I hereby certify that the information provided in my employment application dated (and any resume or other materials submitted by me in connection with my effort to obtain employment with the Hancock County Library System) is true, complete, and accurate. I also understand that any false or misleading information or significant omissions may disqualify me from any further consideration for employment with the Hancock County Library System, or could be justification for dismissal from employment, if discovered at any point after I have been hired or offered employment. B. Release Of Claims Against Providers Of References And/Or Other Employment-Related Information: With the exception of contacting my current employer (discussed below), I fully authorize the investigation and verification of any statements made by me in my employment application dated (and any resume or other materials submitted by me in connection with my effort to obtain employment with the Hancock County Library System). I expressly authorize you to contact all listed past employers and/or references. I further authorize any person, school, past employer, or other person, organization, or entity listed in my application, and any resume or other materials submitted by me to provide the Hancock County Library System with any information requested that may be relevant and useful to the Hancock County Library System in making a hiring decision. I expressly release any such persons, organizations, or entities from any and all legal liability for making disclosure of any information about me, which it is permitted, by law, to release. C. Contact With Current : I DO / DO NOT authorize the Hancock County Library System to contact my current employer. If, and only if, I have authorized the Hancock County Library System to contact my current employer, I agree that the terms set forth in paragraph B also apply to my current employer. D. I agree to have my name submitted to a criminal background check and, if I am offered the position, I will allow the Hancock County Library System to use my date of birth and/or Social Security Number as the identifying term. Print Name: Signed: Date: Social Security Number (voluntary):