SLDA and SLGNA Application

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APPLICATION FOR EMPLOYMENT

SLDA - SLGNA

 

 

 

INSTRUCTIONS TO APPLICANTS

 

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

 

THE STATE EMPLOYS ONLY US CITIZENS OR ALIENS WHO CAN PROVIDE PROOF OF IDENTITY AND WORK AUTHORIZATION WITHIN 3 WORKING DAYS OF EMPLOYMENT MALES SUBJECT TO MILITARY SELECTIVE SERVICE REGISTRATION MUST CERTIFY COMPLIANCE TO BE ELIGIBLE FOR STATE EMPLOYME NT (G.S. 143B-421.1). SEE AVAILABILITY BLOCK.

 

WHEN COMPLETING THIS APPLICATION, PLEASE MAKE SURE YOU

         COMPLETE THE SECTION FOR EQUAL OPPORTUNITY INFORMATION.

         APPLY FOR ONE VACANCY PER APPLICATION.

         IF YOU ARE A RIF APPLICANT WITH PRIORITY- PLEASE CHECK THE APPROPRIATE BOX.

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

 

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

 

         AS YOU DESCRIBE YOUR WORK HISTORY, MAKE SURE YOU HIGHLIGHT YOUR COMPETENCIES  (KNOWLEDGE, SKILLS, ABILITIES AND WORK BEHAVIORS) WHICH DEMONSTRATE YOUR QUALIFICATIONS FOR THE POSITION FOR WHICH YOU ARE APPLYING.

 

         PROVIDE ONLY THE LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NUMBER.

         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 I TS CITIZENS. ALTHOUGH EVERYONE WHO APPLIES CANNOT BE HIRED, YOUR APPLICATION WILL BE GIVEN EVERY CONSIDERATION.

 

PD 107 (REV 06/2009)

Equal Opportunity Information

State Government policy prohibits discrimination based on race, sex, color, creed, national origin, age or disability. Sex, age or absence of disability 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

 

                         _____  (Month)  (Day)   (Year)

 

 

Gender

 

 

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               G     Respiratory impairment

B     Blind or severely visually                H     Nervous system/Neurological impaired                                               disorder

C     Deaf or severely hearing                I       Mentally restored

impaired                                        J      Mental retardation

D     Loss of limited use of arms            K     Learning disability

and/or hands                                 L      Others (heart disease, diabetes,

E     Non-ambulatory (must use                     speech impairment)

wheelchair)                                    M     Other (please specify)

F     Other orthopedic impairment

(including amputation, arthritis, back injury, cerebral palsy, spina bifida, etc.)


 

APPLICATION FOR EMPLOYMENT      SLDA - SLGNA

Date of Application

Last 4 digits of Social Security No.

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 SLDA – S:GNA?

YES      NO

 

Are you a layoff candidate with the SLDA - SLGNA. eligible for RIF priority reemployment consideration .                                        YES        NO   Notification Date:                                    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 spouses) qualifying active military service:

Entered:                                                Separated:                                                 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.

Job Applied For

Enter below the specific title and vacancy number of the job for which you are applying.

 

Job Title:                                                                                                    Vacancy Number:                                                                                           

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 NO

 

 

 

College(s) University (s)

 

 

YES NO

 

 

 

Graduate or

Professional

 

 

YES NO

 

 

 

Other educational, vocational school,

internships, etc.

 

 

YES NO

 

 

 

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.                                    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

 Person Responsible:


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

SKILLS

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

 

Driver’s License                                                        Sign Language                                                              Legal transcription

Number                 State              Foreign language (specify)                                           Medical transcription

Chauffeur’s License                                                 Adding Machine/calculator                                           Braille

Number                 State              Typing (specify WPM)                                                 Word Processing

Car for use at work                                                    Shorthand/speedwriting (specify WPM)                          Other                                                      

WORK HISTORY (include volunteer experience) Use additional sheets if necessary. As you describe your work history experiences, make sure you highlight your competencies which demonstrate your qualifications for the position for which you are applying.

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)

List major duties that demonstrate your competencies related to the position for which you are applying in order of their importance in the job:

Full Time        Years        Months

Part Time       Years        Months

If part time, number of hours worked per week:

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)

List major duties that demonstrate your competencies related to the position for which you are applying in order of their importance in the job:

Full Time        Years        Months

Part Time       Years        Months

If part time, number of hours worked per week:

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)

List major duties that demonstrate your competencies related to the position for which you are applying in order of their importance in the job:

Full Time        Years        Months

Part Time       Years        Months

If part time, number of hours worked per week:

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.

 

 

Signature of Applicant (unsigned applications will not be processed)                                                  Date