Record of employment – last five years:
Employer
Length of Service
Reason for leaving
Three character references (other than family member). The undersigned certify that we know applicant to be
of good moral character:
Name
Address
The undersigned applicant hereby certifies that all statements, oaths, information and schedules attached hereto
are hereby made a part of this application and that all statements, oaths, information and schedules contained
herein are true and correct. This the ______________ day of ___________________________, ________.
_____________________________
Signature of Applicant
State of Mississippi
County of ________________________________________
This day personally came and appeared before me, the undersigned authority in and for the jurisdiction
aforesaid, _________________________________ who, being by me first duly sworn, states on oath that the
matters and things in the foregoing instruments are true and correct as herein stated.
_____________________________
Affiant
Sworn to and subscribed before me on this the ________ day of __________________________ _________.
_____________________________
Notary Public
My Commission expires ___________________________.
NOTE: THE FOLLOWING MUST BE ATTACHED TO THIS APPLICATION:
1. $5,000 surety bond payable to the State of Mississippi
2. Weighmaster’s Oath (Signed by applicant)
3. State that weighing device has been tested and declared to be accurate, within tolerance allowed by NBS
Handbook 44 for such device, by state weights and measures jurisdiction.
4. Check or money order in the amount of $25.00 payable to the Mississippi Department of Agriculture and
Commerce.