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STATE OF MISSISSIPPI APPLICATIONReturn Completed Application to:Mississippi State Personnel Board210 East Capitol Street, Suite 800Jackson, MS 39201www.mspb.ms.govFor Staff/Official Use OnlyReceived:Important! Please Read Before you begin the application process:Please submit one application per job posting. Please be sure to complete the entire application. Applications lacking sufficientinformation will be processed and returned as invalid. Please ensure your application is received or postmarked by the closing date asindicated on the job posting.-TYPE OR PRINT IN BLACK INK-JOB INFORMATIONJOB NUMBER:POSITION TITLE:PERSONAL INFORMATIONFIRST NAMEMIDDLE INITIALLAST NAMEADDRESSCITYSTATEZIPHOME PHONEALTERNATE PHONEMONTH AND DATE OF BIRTHWHICH METHOD DO YOU PREFER TO BE NOTIFIED ABOUT YOURAPPLICATION STATUS?EMAIL ORPAPEREMAIL ADDRESSEDUCATIONWHAT IS YOUR HIGHEST LEVEL OF EDUCATION:Some High SchoolHigh SchoolSome CollegeTechnical CollegeAssociate’s DegreeBachelor’s DegreeMaster’s DegreeSpecialist’s DegreeHIGH SCHOOL EDUCATIONDID YOU GRADUATE FROM HIGH SCHOOL/RECEIVE A G.E.D.?YESIF NO, WHAT WAS THE HIGHEST GRADE LEVEL COMPLETED?7NO89101112COLLEGE/UNIVERSITY EDUCATIONSCHOOL NAMEDATES ATTENDEDDEGREE RECEIVEDDID YOU GRADUATE?YESNOSCHOOL LOCATION (CITY/STATE)MAJORSCHOOL NAMEDATES ATTENDEDDEGREE RECEIVEDDID YOU GRADUATE?YESNOSCHOOL LOCATION (CITY/STATE)SCHOOL LOCATION (CITY/STATE)Rev 5/2011SEMESTERQUARTER# OF UNITS COMPLETED:MAJORSCHOOL NAMEDATES ATTENDEDSEMESTERQUARTER# OF UNITS COMPLETED:DEGREE RECEIVEDSEMESTERQUARTER# OF UNITS COMPLETED:DID YOU GRADUATE?YESNOMAJORDoctorate Degree
CERTIFICATES & LICENSESTYPEDATE ISSUED (MONTH/YEAR)EXPIRATION DATE (MONTH/YEAR)LICENSE NUMBERISSUING AGENCYSPECIALIZATIONTYPEDATE ISSUED (MONTH/YEAR)EXPIRATION DATE (MONTH/YEAR)LICENSE NUMBERISSUING AGENCYSPECIALIZATIONTYPEDATE ISSUED (MONTH/YEAR)EXPIRATION DATE (MONTH/YEAR)LICENSE NUMBERISSUING AGENCYSPECIALIZATIONWORK HISTORYDATESFromToEMPLOYERPOSITION TITLEADDRESS, CITY, STATEPHONE NUMBERSUPERVISOR (NAME & TITLE)HOURS PER WEEKSALARYMAY WE CONTACT THIS EMPLOYER?YESNOEMPLOYERPOSITION TITLEDUTIESDATESFromToADDRESS, CITY, STATEPHONE NUMBERSUPERVISOR (NAME & TITLE)HOURS PER WEEKSALARYMAY WE CONTACT THIS EMPLOYER?YESNODUTIES2Rev 5/2011
WORK HISTORYDATESFromEMPLOYERPOSITION TITLEToADDRESS, CITY, STATEPHONE NUMBERSUPERVISOR (NAME & TITLE)HOURS PER WEEKSALARYMAY WE CONTACT THIS EMPLOYER?YESNOEMPLOYERPOSITION TITLEDUTIESDATESFromToADDRESS, CITY, STATEPHONE NUMBERSUPERVISOR (NAME & TITLE)HOURS PER WEEKSALARYMAY WE CONTACT THIS EMPLOYER?YESNODUTIES3Rev 5/2011
AGENCY WIDE QUESTIONS1. ARE YOU CURRENTLY EMPLOYED WITH THE STATE OF MS?YESNO2. 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)? YESNO4. IF YOU ANSWERED “YES” TO THE PREVIOUS QUESTION, INDICATE WHICH AGENCY, YOUR PREVIOUS JOB TITLE, AND THE DATE OF YOUR RIFSEPARATION. (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?YESNO(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?YESNO7. ARE YOU AN ADULT MALE BORN ON OR AFTER JANUARY 1, 1960 WHO REGISTERED FOR SELECTIVE SERVICE BETWEEN THE AGES OF 18 AND 25?YESNOTO MEET THE REQUIREMENTS OF FEDERAL REGULATIONS, MSPB NEEDS TO COLLECT INFORMATION ON THE QUESTIONS BELOW FORREPORTING PURPOSES ONLY. THIS INFORMATION WILL NOT BE USED FOR MAKING EMPLOYMENT DECISIONS. (OPTIONAL)8. INDICATE YOUR RACEAMERICAN INDIANWHITEHISPANICBLACKASIANOther9. INDICATE YOUR GENDERMALEFEMALE10. AGE GROUP:UNDER 1818-2526-3940-5455-6970 ADDITIONAL INFORMATIONAdditional Information (other schools or training; special qualifications; honors and awards; etc.):APPLICANT DECLARATIONSBy 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. Iauthorize the verification of this information by the Mississippi State Personnel Board and any agency considering me for employment. I know that anymisrepresentation herein may lead to rejection of my application, removal of my name from the list of eligibles, and/or dismissal from state service. Iunderstand that, as a condition of employment, I will be required to present documentation which verifies both my identity and my employment eligibilitypursuant to federal immigration law.XSIGNATURE OF APPLICANT4Rev 5/2011DATE
Supplemental PageLast NameFirst NameJOB INFORMATIONJOB NUMBER:POSITION TITLE:COLLEGE/UNIVERSITY EDUCATIONSCHOOL NAMEDEGREE RECEIVEDDATES ATTENDEDDID YOU GRADUATE?YESNOSCHOOL LOCATION (CITY/STATE)SEMESTERQUARTER# OF UNITS COMPLETED:MAJORSCHOOL NAMEDEGREE RECEIVEDDATES ATTENDEDDID YOU GRADUATE?YESNOSCHOOL LOCATION (CITY/STATE)DATES ATTENDEDMAJORCERTIFICATES & LICENSESTYPEDATE ISSUED (MONTH/YEAR)EXPIRATION DATE (MONTH/YEAR)LICENSE NUMBERISSUING AGENCYSPECIALIZATIONTYPEDATE ISSUED (MONTH/YEAR)EXPIRATION DATE (MONTH/YEAR)LICENSE NUMBERISSUING AGENCYSPECIALIZATIONWORK HISTORYDATESFromEMPLOYERPOSITION TITLEToADDRESSCITYSTATECOMPANY WEBSITEPHONE NUMBERSUPERVISOR (NAME & TITLE)HOURS WORKED PER WEEKMONTHLY SALARYMAY WE CONTACT THIS EMPLOYER?YESNODUTIES5Rev 5/2011
Mississippi State Personnel Board 210 East Capitol Street, Suite 800 Jackson, MS 39201 www.mspb.ms.gov For Staff/Official Use Only Received: _ Important! Please Read Before you begin the application process: Please submit one application per job posting. Please be sure to complete the entire application.
