南卡拉羅那州政府應聘人員申請表
Other (Specify) No If no, give total credit received Yes No Yes No A B C D E F M G Yes No Yes No Yes No Male Female American Indian / Alaskan Native Asian / Pacific Islanders Black / Non Hispanic Hispanic White / Non Hispanic Yes No Yes No ----------------------- 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) Date Signature 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. Date Signature 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. Date Signature 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. PLEASE CAREFULLY READ THE FOLLOWING STATEMENTS Phone Address Name Phone Address Name Give the names of two people, not relatives, who are familiar with your work. Are you legally authorized to work in the United States? If yes, explain Have you ever been terminated or forced to resign from any job? Disposition/Status Date Where Convicted If yes, please list charge(s) Note: Omit minor vehicle violations and any offense committed before your 17th 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. Have you ever been convicted of a criminal offense? Agency Relation Name Agency Relation Name Do you have any relatives employed with the State of South Carolina? If yes, please provide names below: Class: (check one) Expiration Date Number (State) If yes, provide Do you possess a valid driver’s license? 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 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?
南卡拉羅那州政府應聘人員申請表