南卡拉罗那州政府应聘人员申请表
Other (Specify)
No
If no, give total credit received
STATE OF SOUTH CAROLINA EMPLOYMENT APPLICATION
RETURN TO:
1. APPLYING FOR:
Job Title
Position Number
Location
2. HOW DO WE CONTACT YOU?
Social Security Number
Your Name
Mailing Address
City
County
State
Zip Code
Home Phone
( )
Business Phone
( )
Fax Number
( )
E-mail Address
3.
TELL US ABOUT YOUR EDUCATION:
High School (Name)
(Location)
Diploma
Highest Grade Completed
College Graduate? Yes
Your Name If Different While Attending School
Give name & address of school, major course of study, and degree received.
Undergraduate College / University
Graduate School
Degree
Year Degree Obtained
Degree
Year Degree Obtained
Pertinent Undergraduate Courses
Credits
Pertinent Graduate Courses
Credits
Job-Related Training and Course Work
List any skills, licenses, and certificates which are related to the job you seek (including words per minute typing speed and computer software proficiency).
STATE OF SOUTH
CAROLINA - AN EQUAL OPPORTUNITY EMPLOYER
PD- 1 DID (REVISED 6/98)
Yes
No
4. TELL US ABOUT YOUR WORK EXPERIENCE:
Describe your work experience in detail, beginning with your current or most recent job. Include military service (indicate rank) and job related volunteer work, if applicable. Provide an explanation for any gaps in employment. All information in this section must be complete. A résumé may be attached, but not substituted for completing this section.
1. Name of Present or Last Employer
Address
Phone
( )
Job Title
Number Supervised
Supervisor"s Name
From
/ / To
/ / Hours Per Week
Salary
May we contact this employer?
Job Duties (give details)
Reason for Leaving
2. Your Next Most Recent Employer
Address
Phone
( )
Job Title
Number Supervised
Supervisor"s Name
From
/ / To
/ / Hours Per Week
Salary
Job Duties (give details)
Reason for Leaving
3. Your Next Most Recent Employer
Address
Phone
( )
Job Title
Number Supervised
Supervisor"s Name
From
/ / To
/ / Hours Per Week
Salary
Job Duties (give details)
Reason for Leaving
4. Your Next Most Recent Employer
Address
Phone
( )
Job Title
Number Supervised
Supervisor"s Name
From
/ / To
/ / Hours Per Week
Salary
Job Duties (give details)
Reason for Leaving
5. Your Next Most Recent Employer
Address
Phone
( )
Job Title
Number Supervised
Supervisor"s Name
From
/ / To
/ / Hours Per Week
Salary
Job Duties (give details)
Reason for Leaving
6. Your Next Most Recent Employer
Address
Phone
( )
Job Title
Number Supervised
Supervisor"s Name
From
/ / To
/ / Hours Per Week
Salary
Job Duties (give details)
Reason for Leaving
Yes
No
A
B
C
D
E
F
M
G
Yes
No
Yes
No
Yes
No
Do you possess a valid driver"s license?
If yes, provide
(State)
Number
Expiration Date
Class: (check one)
Do you have any relatives employed with the State of South Carolina? If yes, please provide names below:
Name
Relation
Agency
Name
Relation
Agency
Have you ever been convicted of a criminal offense?
Note: Omit minor vehicle violations and any offense committed before your 17 th
birthday, which was finally adjudicated in juvenile court or under a youthful offender law. Conviction of a criminal offense is not a bar to employment in all cases. Each conviction is evaluated individually.
If yes, please list charge(s)
Where Convicted
Date
Disposition/Status
Have you ever been terminated or forced to resign from any job?
If yes, explain
Are you legally authorized to work in the United States?
Give the names of two people, not relatives, who are familiar with your work.
Name
Address
Phone
Name
Address
Phone
PLEASE CAREFULLY READ THE FOLLOWING STATEMENTS
Student Loan: State law (59-111-50) prohibits employment with the State to people who have defaulted on certain student loans, unless they can prove that satisfactory arrangements have been made for repayment. By my signature, I certify that I am not currently in default on a student loan.
Signature
Date
Authority to Release Information: By my signature, I consent to the release of information to authorized officers, agents, and/or employees of the State of South Carolina which may include but not be limited to information concerning my past and present work; including my official personnel files; attendance records; evaluations; educational records including transcripts; military service; law enforcement records; and/or any personnel record deemed necessary. In addition, I consent to authorize appropriate officers, agents, and/or employees of the State of South Carolina to make inquiries of third parties such as credit bureaus. I further release the organization, educational entity, present and former employers, law enforcement organization, and all third parties from any and all claims of whatever nature that I may have as a result of any inquiry or response given to such inquiries made in connection with my application for employment.
Signature
Date
Certification of Applicant:
By my signature, I affirm, agree, and understand that all statements on this form are true and accurate. Any misrepresentation, falsification, or material omission of information or data on this application may result in exclusion from further consideration or, if hired, termination of employment. If I have requested herein that my present employer not be contacted, an offer of employment may be conditioned upon acceptable information and verification from such employer prior to beginning work.
Signature
Date
Male
Female
American Indian / Alaskan Native
Asian / Pacific Islanders
Black / Non Hispanic
Hispanic
White / Non Hispanic
Yes
No
Yes
No
5. EEO DATA REPORTING FORM:
The federal government requires the following information to be collected for statistical reporting as a part of the Affirmative Action Program. Refusal to answer will not result in adverse treatment of any applicant. This information is not used in the employment process nor released in a manner which identifies the individual. This form will be removed prior to being forwarded to the hiring authority.
Today"s Date
/ / Social Security Number
Last Name
First Name
Middle
Position for which you are applying
Title
Position Number
Sex
(Check appropriate box)
Date of Birth
/ / Race (Check appropriate box)
1.
2.
3.
4.
5.
Will you need reasonable accommodations to participate in the selection procedures (e.g., interview, written tests, or job demonstration)?
If yes, please notify the Personnel Office or Human Resources Office at the state agency which has the job vacancy.
State agencies are actively supporting the Family Independence Act by hiring welfare and food stamp recipients for certain jobs. Are you currently receiving AFDC benefits or food stamps?