Application for Employment

NOTICE:

1. TO BE CONSIDERED FOR STATE EMPLOYMENT, YOU MUST ANSWER ALL QUESTIONS AND COMPLETE ALL SECTIONS OF THIS APPLICATION FORM.

2. THE STATE EMPLOYS ONLY US CITIZENS OR ALIENS WHO CAN PROVIDE PROOF OF IDENTITY AND WORK AUTHORIZATION WITHIN 3 WORKING DAYS OF EMPLOYMENT

3. MALES SUBJECT TO MILITARY SELECTIVE SERVICE REGISTRATION MUST CERTIFY COMPLIANCE TO BE ELIGIBLE FOR STATE EMPLOYMENT (G.S. 143B-421.1). SEE AVAILABILITY BLOCK.

WHEN COMPLETING THIS APPLICATION, PLEASE MAKE SURE YOU:

1. COMPLETE THE SECTION FOR EQUAL OPPORTUNITY INFORMATION.

2. GIVE COMPLETE INFORMATION ON YOUR EDUCATION AND WORK HISTORY (“SEE RESUME” IS NOT ACCEPTABLE.)

3. LIST SEPARATELY EACH JOB HELD AND YOUR DUTIES FOR EACH POSITION WHEN YOU WORKED FOR ONE EMPLOYER AND HELD MORE THAN ONE POSITION.

4. CHECK FOR ACCURACY, SIGN AND DATE YOUR APPLICATION.

THANK YOU FOR YOUR INTEREST IN STATE GOVERNMENT. NORTH CAROLINA WANTS TO FIND THE BEST QUALIFIED PEOPLE AVAILABLE TO SERVE ITS CITIZENS. ALTHOUGH EVERYONE WHO APPLIES CANNOT BE HIRED, YOUR APPLICATION WILL BE GIVEN EVERY CONSIDERATION.

APPLICATION FOR EMPLOYMENT

(SSN Voluntary, for Record Keeping and Data Processing Only)

STATE OF

NORTH CAROLINA

Date of Application

Social Security Number

Last Name

First Name

Middle Name

Address (Street number and name)

City

County

State

Zip Code

Phone (Home or where you can be reached)

Business Phone

Availability

Do you now work for the State of NC?

YES NO

Are you related by blood or marriage to any person now working for the State YES NO

If yes, give name, relationship to you and the agency where employed.

If subject to Military Selective Service registration, certify compliance by initialing dotted line

............................................ ............................................ ..................................

Military Service

Have you served honorably in the Armed Forces of the United States on active duty for reasons other than training? YES NO

Do you wish to declare a service-connected disability? YES NO

At the time of this application, are you the surviving spouse or dependent of a deceased veteran who died from service-related reasons? YES NO

Do you wish to declare eligibility for veterans preference as the spouse of a disabled veteran? YES NO

Give dates of your (or spouse’s) qualifying active military service:

Entered: Separated: Branch: Rank

Are you a member of the Military Reserves? YES NO Branch: Rank:

AGENCY USE ONLY: ELIGIBILITY FOR VETERAN’S PREFERENCE: YES NO

CHECK the types of work you will accept: 1. Permanent full-time 2. Permanent part-time 3. Temporary full-time 4. Temporary part-time 5. Any of the preceding 6. Work involving Travel 7. Shift or Split Shift Work

If you are not available for work now, enter the earliest date you could begin work (mo/day/yr.)

Will you accept work anywhere in N.C.? YES NO (If no, list below the counties in which you would be willing to work.)

1. 2. 3. 4. 5.

Jobs Applied For

Enter below the specific title(s) of the job(s) for which you are applying. Please list no more than three on this application.

1. 2. 3.

Referral Source

Please indicate your referral source:

If you were referred by the Employment Security Commission (Job Service) please indicate which local office:

Education

Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED College 1 2 3 4 Graduate School 1 2 3 4

Under S/Q Hrs., list the hours of credit received and if they were semester (S) or quarter (Q) hours.

Schools

Name and Location

Dates Attended (mo/yr)

From: To:

Grad?

S/Q Hrs.

Major/Minor Course Work

Type of Degree Received

High School

YES

College(s)

University (s)

YES

Graduate or

Professional

YES

Other educational, vocational school, internships, etc.

YES

Special training programs and seminars you have completed in the last five years (list):

If the job(s) applied for calls for specific courses, indicate those courses taken and credits received:

Current professional status: (List fields of work for which you have been registered)

Registration: State: No.

Membership in professional, honorary, or technical societies (list):

DO NOT COMPLETE THIS BLOCK

DEGREES AND PROFESSIONAL CREDENTIALS

Have been verified

Will be verified within 90 days (G.S. 126-30)

Person Responsible:

PD 107 (REV. 3/95)

Equal Opportunity Information

State Government policy prohibits discrimination based on race, sex, color, creed, national origin, age or disability. Sex or age is a bona fide occupational qualification in a small number of State jobs. The information requested below will in no way affect you as an applicant. Its sole use will be to see how well our recruitment efforts are reaching all segments of the population.

Date of Birth

(mo.) (day) (year)

Check One

SEX

M F

(male) (female)

DISABILITY: “Disability means, with respect to an individual: (1) a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (2) a record of such an impairment; or (3) being regarded as having such an impairment” (Americans with Disabilities Act of 1990). Persons without a disability should check item A.

The reporting of a disability is strictly VOLUNTARY. Persons with disabilities who DO NOT WISH to report their disabilities should check item A. Information reported on this form will be kept confidential as required by State law. Public disclosure of this information without your consent would be a violation of G.S. 126-27.

ETHNIC GROUP

1. White (non-Hispanic)

2. Black (non-Hispanic)

3. Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, other Spanish origin regardless of race)

4. Asian (including Pacific Islander)

5. American Indian (including Alaskan native)

A None/Prefer not to report

B Blind or severely visually impaired

C Deaf or severely hearing impaired

D Loss of limited use of arms and/or hands

E Non-ambulatory (must use wheelchair)

F Other orthopedic impairment (including amputation, arthritis, back injury, cerebral palsy, spina bifida, etc.)

G Respiratory impairment

H Nervous system/Neurological disorder

I Mentally restored

J Mental retardation

K Learning disability

L Others (heart disease, diabetes, speech impairment)

M Other (please specify)

Licenses and certifications (List, giving dates and sources of issuance):

SKILLS

CHECK the following skills, experiences, etc., which you have:

Driver’s License

Number State

Chauffeur’s License

Number State

Car for use at work

Sign Language

Foreign language (specify)

Adding Machine/calculator

Typing (specify WPM)

Shorthand/speedwriting (specify WPM)

Legal transcription

Medical transcription

Braille

Word Processing

Other

Have you ever been convicted of an offense against the law other than a minor traffic violation? (A conviction does not mean you cannot be hired. The offense and how recently you were convicted will be evaluated in relation to the job for which you are applying.) YES NO (If yes, explain fully on an additional sheet.)

WORK HISTORY (include volunteer experience) Use Additional Sheets if Necessary

Current or Last Employer:

Address:

Job Title:

Supervisor’s Name

Telephone Number

No. Supervised by you:

Date Employed (mo/yr)

Starting Salary

$ per

Ending or Current Salary

$ per

Reason for Leaving

May We Contact Employer

YES NO

Date Separated (mo/yr)

Full Time Years Months

Part Time Years Months

If part time, number of hours worked per week:

List major duties in order of their importance in the job:

Employer:

Address:

Job Title:

Supervisor’s Name

Telephone Number

No. Supervised by you:

Date Employed (mo/yr)

Starting Salary

$ per

Ending or Current Salary

$ per

Reason for Leaving

Date Separated (mo/yr)

Full Time Years Months

Part Time Years Months

If part time, number of hours worked per week:

List major duties in order of their importance in the job:

Employer:

Address:

Job Title:

Supervisor’s Name

Telephone Number

No. Supervised by you:

Date Employed (mo/yr)

Starting Salary

$ per

Ending or Current Salary

$ per

Reason for Leaving

Date Separated (mo/yr)

Full Time Years Months

Part Time Years Months

If part time, number of hours worked per week:

List major duties in order of their importance in the job:

I certify that I have given true, accurate and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigation of all statements made in this application and understand that false information or documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and (or) criminal action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications (Authority: G.S. 126-30, G.S. 14-122.1.)

Signature of Applicant (unsigned applications will not be processed)

Date