Request for Applications (RFA) Legal Assistant Developer (LAD) RFx# 3140004566

STATE OF MISSISSIPPI APPLICATION
Return Completed Application to: For Staff/Official Use Only
Kimbley Hendrix
Mississippi Department of Human Services Received: __________________
Division of Procurement Services 200 South
Lamar Street Jackson, MS 39201
Important! Please Read Before you begin the application process:
Applicants must complete and attach the "Supplemental Questions" page when applicable. This page is located on the MSPB
website Job Openings screen. Scroll down to the bottom of the screen and click the preferred job; when the description is displayed,
click "Print Job Information." Applications failing to include this page or lacking sufficient information will be returned to the applicant
as invalid. Please ensure your application is received by the closing date as indicated on the job posting.
-TYPE OR PRINT IN BLACK INK-
JOB INFORMATION
POSITION #: POSITIONTITLE:
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.? 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 SEMESTER QUARTER
DID YOU GRADUATE?
# OF UNITS COMPLETED:
YES NO
SCHOOL LOCATION (CITY/STATE) MAJOR
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED SEMESTER QUARTER
DID YOU GRADUATE?
# OF UNITS COMPLETED:
YES NO
SCHOOL LOCATION (CITY/STATE) MAJOR
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED SEMESTER QUARTER
DID YOU GRADUATE?
# OF UNITS COMPLETED:
YES NO
SCHOOL LOCATION (CITY/STATE) MAJOR
Rev 2/2012

CERTIFICATES & LICENSES
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
WORK HISTORY
DATES EMPLOYER POSITION TITLE
From To
ADDRESS, CITY, STATE
PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO
DUTIES
DATES EMPLOYER POSITION TITLE
From To
ADDRESS, CITY, STATE
PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO
DUTIES
2
Rev 3/2012

WORK HISTORY
DATES EMPLOYER POSITION TITLE
From To
ADDRESS, CITY, STATE
PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO
DUTIES
DATES EMPLOYER POSITION TITLE
From To
ADDRESS, CITY, STATE
PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO
DUTIES
3
Rev 3/2012

AGENCY WIDE QUESTIONS
1. ARE YOU CURRENTLY EMPLOYED WITH THE STATE OF MS? YES NO
2. 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)? YES NO
4. IF YOU ANSWERED "YES" TO THE PREVIOUS QUESTION, INDICATE WHICH AGENCY, YOUR PREVIOUS JOB TITLE, AND THE DATE OF YOUR RIF
SEPARATION. (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? YES NO
(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? YES NO
7. ARE YOU AN ADULT MALE BORN ON OR AFTER JANUARY 1, 1960 WHO REGISTERED FOR SELECTIVE SERVICE BETWEEN THE AGES OF 18 AND 25?
YES NO
TO MEET THE REQUIREMENTS OF FEDERAL REGULATIONS, MSPB NEEDS TO COLLECT INFORMATION ON THE QUESTIONS BELOW FOR
REPORTING PURPOSES ONLY. THIS INFORMATION WILL NOT BE USED FOR MAKING EMPLOYMENT DECISIONS. (OPTIONAL)
8. INDICATE YOUR RACE 9. INDICATE YOUR GENDER 10. AGE GROUP:
AMERICAN INDIAN MALE UNDER 18
WHITE FEMALE 18-25
26-39
HISPANIC
40-54
BLACK
55-69
ASIAN 70+
Other
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 Mississippi State Personnel Board and any agency considering me for employment. I know that any
misrepresentation herein may lead to rejection of my application, removal of my name from the list of eligibles, and/or dismissal from state service. 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
4
Rev 3/2012

SUPPLEMENTAL QUESTIONS
Applicants must complete and attach the "Supplemental Questions" page when applicable. This page is located on the
MSPB website Job Openings screen. Scroll down to the bottom of the screen and click the preferred job; when the description is
displayed, click "Print Job Information." Applications failing to include this page or lacking sufficient information will be returned to
the applicant as invalid. Please ensure your application is received by the closing date as indicated on the job posting.
ADDITIONAL WORK HISTORY
JOB INFORMATION
JOB NUMBER: POSITION TITLE:
COLLEGE/UNIVERSITY EDUCATION
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED DID YOU GRADUATE? SEMESTER QUARTER
YES NO # OF UNITS COMPLETED:
SCHOOL LOCATION (CITY/STATE) MAJOR
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED DID YOU GRADUATE? DATES ATTENDED
YES NO
SCHOOL LOCATION (CITY/STATE) MAJOR
CERTIFICATES & LICENSES
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
WORK HISTORY
DATES EMPLOYER POSITION TITLE
From To
ADDRESS CITY STATE
COMPANY WEBSITE PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS WORKED PER WEEK MONTHLY SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO
DUTIES
5
Rev 3/2012