Legal Authorization *

Proof of citizenship or immigration status will be required upon employment.

Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Senatobia Police Department Authorization for Release of Information Agreement - TO WHOM IT MAY CONCERN: I am an applicant for a position with the Senatobia, Mississippi Police Department. The department needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I applied. It is in the public's interest that all relevant information concerning my personal and employment history be disclosed to the above department. I hereby authorize any representative of the Senatobia Police Department bearing this release to obtain any inforn1ation in your files pertaining to my employment records and I hereby direct you to release such information upon request of the bearer. I do hereby authorize a review of and full disclosure of all records, or any part thereof, concerning myself, by and to any authorized agent of Senatobia Police Department, whether said records are of public, private, or confidential nah1re. The intent of this authorization is to give my consent for full and complete personnel information, however personal or confidential it may appear to be. I consent to your release of any and all public and private information that you may have concerning me, my work, record, my background and reputation, my military service records, educational records, my financial status, my criminal history record, including any arrest records, any information contained in investigatory files, efficiency rating, complaints or grievances filed by or against me, the records or recollections of attorneys at law or other counsel, whether representing me or another person in any case either criminal or civil, in which I presently have, or have had an interest, attendance records, polygraph examinations, and any internal affairs investigations and discipline, including any files which are deemed to be confidential, and/or sealed. I hereby release you, your organization, and all others from liability or damage pursuant to any state or federal laws. I hereby release you, as the custodian of such records of your organization, including its officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request of the duly accredited representative of the Senatobia Police Department regardless of any agreement I may have made with you previously to the contrary. The law enforcement organization requesting the information pursuant to this release with discontinue processing my application if you refuse to disclose the information requested. For and in consideration of the Senatobia Police Department's acceptance and processing of my application for employment, I agree to hold your organization, its agents and employees harmless from any, and all claims and liability associated with application for employment or in any way connected with the decision whether or not to employ me with the Senatobia Police Department. I understand that should information of serious criminal nature surface as result of this investigation, such infom1ation may be h1rned over to the proper authorities. I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974, with regards to access and disclosure of records and I waive those rights with the understanding that information furnished will be used by the Senatobia Police Department in conjunction with employment procedures. A photocopy or fax copy of this release form will be valid as an original thereof, even though the said photocopy or fax copy does not contain an original writing of my signature. This waiver is valid for a period of 90 days from the date of my signature. Should there be any questions as to the validity of this release, you may contact me at the address listed on this form. I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this f01m. I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees, from and against all claims and damages, losses and expenses, including reasonable attorney's fees, arising out of or by reason of complying with this request. *
Able to meet attendance requirements? *

Certain relationships between applicants for City positions, City employees or elected officials could constitute violations of State law or City policy if the applicant were hired. In order to assist the city in determining if a prohibited relationship exists, please identify below any and all persons related to you birth, marriage, or otherwise who are employed by the City of Senatobia or that are elected officials: 

Education Details

ACQUIRED SKILLS
PLEASE CHECK AREAS IN WHICH YOU HAVE HAD EXPERIENCE OR TRAINING

Background Information

Personal Information

List three people, other than relatives, who have knowledge of your character and/or ability.

Employment History

IMPORTANT:

  1. LIST BELOW ALL PRESENT AND PAST EMPLOYMENT, FOR THE PAST TEN YEARS, BEGINNING WITH THE MOST RECENT JOB HELD. Attach additional sheets if necessary.
  2. TAKE TIME TO FILL IN THE DATA CAREFULLY AND COMPLETELY. ONE OF THE WAYS QUALIFICATIONS ARE ACCESSED IS BASED ON THE DATA YOU ENTER ON YOUR EMPLOYMENT HISTORY.
  3. INDICATE IF YOU ARE NOW UNEMPLOYED OR IF YOU HAVE NEVER BEEN EMPLOYED.
If currently employed, may we contact your supervisor?
Add another Job?
If currently employed, may we contact your supervisor?
Add a 3rd Job?
If currently employed, may we contact your supervisor?

Other Details

Do you have a non-compete clause, a confidentiality obligation, or a contractual obligation with your current or former employer that has not yet expired that could impact your ability to work at the City of Senatobia in the position for which you have applied? *

If you have answered "yes" to this question, please contact the HR Department, and provide complete copies thereof.

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PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING

I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment. Any misrepresentation or omission made on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered.

I understand, where permissible under applicable state and local law, after receiving a conditional offer of employment, I may be subject to a pre-employment medical examination which could include a pre-employment drug test, and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work with the City of Senatobia.

I hereby certify that the information given by me is true in all respects. I authorize the City of Senatobia and its representatives to contact my prior employers, and all other references provided for the purpose of verifying the information I have supplied and release same from any liability resulting from the information released. I authorize employers, schools, and other people named on this application to provide any information or transcripts requested..

I understand employment with the City of Senatobia is also contingent on providing sufficient documentation necessary to establish my identity and eligibility to work in the United States.

I understand that this application is current for 60 days. At the conclusion of this time, if I have not heard from the City of Senatobia and still wish to be considered for employment, it will be necessary to fill out a new application. 

I expressly understand and agree that, if employed, my employment, having no specified term, is based upon mutual consent, and may be terminated at will, with or without cause, by either party (the employer or me) without prior notice to the other, unless otherwise prohibited by law.

I understand that no representation, whether oral or written, by any representative or agent of the City of Senatobia, at any time, shall constitute an implied or expressed contract of employment, nor guarantee of continued employment, and I acknowledge that the City of Senatobia reserves the right to modify company policies, procedures, manuals and similar documents at any time. I further understand that no representative or agent of the City of Senatobia has the authority to enter into an agreement for employment for any specified period or to make any employment contract or agreement contrary to the foregoing, except in a written agreement with me signed by the City of Senatobia Board of Aldermen.

I certify, under the penalty of perjury, that all of the above information is true and complete, and I understand that any falsification or omission of information may result in denial of employment or, if hired, may result in termination regardless of the time lapse before discovery. I VOLUNTARILY WAIVE AND RELEASE PRIOR EMPLOYERS FROM ANY AND ALL LIABILITY FOR PROVIDING INFORMATION IN CONNECTION WITH THIS APPLICATION. MY SIGNATURE IS EVIDENCE THAT I HAVE READ AND AGREE WITH THE ABOVE STATEMENTS.