南卡拉罗那州政府应聘人员申请表

Other(Specify)NoIfno,givetotalcreditreceivedSTATEOFSOUTHCAROLINAEMPLOYMENTAPPLICATIONRETURNTO:1.APPLYINGFOR:JobTitlePositionNumberLocation2.HOWDOWECONTACTYOU?SocialSecurityNumberYourNameMailingAddressCityCountyStateZipCodeHomePhone()BusinessPhone()FaxNumber()E-mailAddress3.TELLUSABOUTYOUREDUCATION:HighSchool(Name)(Location)DiplomaHighestGradeCompletedCollegeGraduate?YesYourNameIfDifferentWhileAttendingSchoolGivename&addressofschool,majorcourseofstudy,anddegreereceived.UndergraduateCollege/UniversityGraduateSchoolDegreeYearDegreeObtainedDegreeYearDegreeObtainedPertinentUndergraduateCoursesCreditsPertinentGraduateCoursesCreditsJob-RelatedTrainingandCourseWorkListanyskills,licenses,andcertificateswhicharerelatedtothejobyouseek(includingwordsperminutetypingspeedandcomputersoftwareproficiency).STATEOFSOUTHCAROLINA-ANEQUALOPPORTUNITYEMPLOYERPD-1DID(REVISED6/98)YesNo4.TELLUSABOUTYOURWORKEXPERIENCE:Describeyourworkexperienceindetail,beginningwithyourcurrentormostrecentjob.Includemilitaryservice(indicaterank)andjobrelatedvolunteerwork,ifapplicable.Provideanexplanationforanygapsinemployment.Allinformationinthissectionmustbecomplete.Arésumémaybeattached,butnotsubstitutedforcompletingthissection.1.NameofPresentorLastEmployerAddressPhone()JobTitleNumberSupervisedSupervisor'sNameFrom//To//HoursPerWeekSalaryMaywecontactthisemployer?JobDuties(givedetails)ReasonforLeaving2.YourNextMostRecentEmployerAddressPhone()JobTitleNumberSupervisedSupervisor'sNameFrom//To//HoursPerWeekSalaryJobDuties(givedetails)ReasonforLeaving3.YourNextMostRecentEmployerAddressPhone()JobTitleNumberSupervisedSupervisor'sNameFrom//To//HoursPerWeekSalaryJobDuties(givedetails)ReasonforLeaving4.YourNextMostRecentEmployerAddressPhone()JobTitleNumberSupervisedSupervisor'sNameFrom//To//HoursPerWeekSalaryJobDuties(givedetails)ReasonforLeaving5.YourNextMostRecentEmployerAddressPhone()JobTitleNumberSupervisedSupervisor'sNameFrom//To//HoursPerWeekSalaryJobDuties(givedetails)ReasonforLeaving6.YourNextMostRecentEmployerAddressPhone()JobTitleNumberSupervisedSupervisor'sNameFrom//To//HoursPerWeekSalaryJobDuties(givedetails)ReasonforLeavingYesNoABCDEFMGYesNoYesNoYesNoDoyoupossessavaliddriver'slicense?Ifyes,provide(State)NumberExpirationDateClass:(checkone)DoyouhaveanyrelativesemployedwiththeStateofSouthCarolina?Ifyes,pleaseprovidenamesbelow:NameRelationAgencyNameRelationAgencyHaveyoueverbeenconvictedofacriminaloffense?Note:Omitminorvehicleviolationsandanyoffensecommittedbeforeyour17thbirthday,whichwasfinallyadjudicatedinjuvenilecourtorunderayouthfuloffenderlaw.Convictionofacriminaloffenseisnotabartoemploymentinallcases.Eachconvictionisevaluatedindividually.Ifyes,pleaselistcharge(s)WhereConvictedDateDisposition/StatusHaveyoueverbeenterminatedorforcedtoresignfromanyjob?Ifyes,explainAreyoulegallyauthorizedtoworkintheUnitedStates?Givethenamesoftwopeople,notrelatives,whoarefamiliarwithyourwork.NameAddressPhoneNameAddressPhonePLEASECAREFULLYREADTHEFOLLOWINGSTATEMENTSStudentLoan:Statelaw(59-111-50)prohibitsemploymentwiththeStatetopeoplewhohavedefaultedoncertainstudentloans,unlesstheycanprovethatsatisfactoryarrangementshavebeenmadeforrepayment.Bymysignature,IcertifythatIamnotcurrentlyindefaultonastudentloan.SignatureDateAuthoritytoReleaseInformation:Bymysignature,Iconsenttothereleaseofinformationtoauthorizedofficers,agents,and/oremployeesoftheStateofSouthCarolinawhichmayincludebutnotbelimitedtoinformationconcerningmypastandpresentwork;includingmyofficialpersonnelfiles;attendancerecords;evaluations;educationalrecordsincludingtranscripts;militaryservice;lawenforcementrecords;and/oranypersonnelrecorddeemednecessary.Inaddition,Iconsenttoauthorizeappropriateofficers,agents,and/oremployeesoftheStateofSouthCarolinatomakeinquiriesofthirdpartiessuchascreditbureaus.Ifurtherreleasetheorganization,educationalentity,presentandformeremployers,lawenforcementorganization,andallthirdpartiesfromanyandallclaimsofwhatevernaturethatImayhaveasaresultofanyinquiryorresponsegiventosuchinquiriesmadeinconnectionwithmyapplicationforemployment.SignatureDateCertificationofApplicant:Bymysignature,Iaffirm,agree,andunderstandthatallstatementsonthisformaretrueandaccurate.Anymisrepresentation,falsification,ormaterialomissionofinformationordataonthisapplicationmayresultinexclusionfromfurtherconsiderationor,ifhired,terminationofemployment.IfIhaverequestedhereinthatmypresentemployernotbecontacted,anofferofemploymentmaybeconditioneduponacceptableinformationandverificationfromsuchemployerpriortobeginningwork.SignatureDateMaleFemaleAmericanIndian/AlaskanNativeAsian/PacificIslandersBlack/NonHispanicHispanicWhite/NonHispanicYesNoYesNo5.EEODATAREPORTINGFORM:ThefederalgovernmentrequiresthefollowinginformationtobecollectedforstatisticalreportingasapartoftheAffirmativeActionProgram.Refusaltoanswerwillnotresultinadversetreatmentofanyapplicant.Thisinformationisnotusedintheemploymentprocessnorreleasedinamannerwhichidentifiestheindividual.Thisformwillberemovedpriortobeingforwardedtothehiringauthority.Today'sDate//SocialSecur