Fillable COUNTY OF LEE APPLICATION FOR EMPLOYMENT (Lee County Government)

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COUNTY OF LEE APPLICATION FOR EMPLOYMENT (Lee County Government)

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COUNTY OF LEE
APPLICATION FOR EMPLOYMENT
ATTENTION
PLEASE READ CAREFULLY……..
All requested information must be furnished. The
information you give will be used to determine your
qualifications for employment. It is IMPORTANT that you
answer all questions on your application fully and
accurately. Give complete information on your education
and work history. (DO NOT PUT "SEE RESUME" UNDER
EDUCATION OR WORK HISTORY).
If an item does not apply to you, or if there is no
information to be given, please write letters "N.A." for Not
Applicable.
This record will be strictly confidential and the exclusive
property of the County of Lee, North Carolina. We are
an Equal Employment Opportunity Employer.
DATE
POSITION (S) APPLIED FOR 1.
2. 3.
NAME
(First) (Middle) (Last)
LEE COUNTY HUMAN RESOURCES
(919) 718-4615 - Phone
(919) 718-4628 - Fax
P.O. BOX 1968 - 408 Summit Drive
SANFORD, NORTH CAROLINA 27331
PERSONAL DATA
PART I:
1. Name:
(Last) (First) (Middle Initial)
2. Phone Number: Home: ( ) Office/Cell: ( )
3. Last Four Digits of SS #:
4. Address of Residence:
(Number and Street or Route)
(City) (County) (State) (Zip Code)
5. Email Address:
EDUCATION AND TRAINING
PART II:
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
DATES ATTENDED
MAJOR OR
TYPE OF
TYPE OF
From To GRADUATE S/Q MINOR FIELD DIPLOMA /
SCHOOL NAME AND LOCATION OF SCHOOL
Mo. Yr. Mo. Yr. (Y/N) HOURS OF STUDY DEGREE
HIGH SCHOOL
COLLEGE OR
UNIVERSITY
TECHNICAL
INSTITUTIONS OR
SCHOOLS
OTHER BUSINESS
TRADE, MILITARY,
ETC.
Special qualifications and skills (licenses, skills with machines, publications, public speaking, memberships in professional associations).
SKILLS: Check the following skills, experience, etc., which you have:
 Drivers license
 Car for use at work
Number & State
 Adding machine/calculator
 CDL
 Word Processing Skills
Number & State
 Computer Skills
 Typing (Specify WPM)
 Legal transcription
 Medical transcription
 Foreign language
 Sign language
 Braille skills
 Other
WORK HISTORY
PART III:
In the space provided below give your employment history, beginning with your PRESENT or most recent employer and list all positions held, including
military, part-time, summer, and volunteer work. Details on any period of unemployment must be included. If additional space is required, please attach
additional sheets using the same format.
Current or Last Employer:
Address:
Job Title: Supervisor's Name: Telephone Number: Number Supervised by you:
Date Employed (mo/yr) Starting Salary Ending or Current Salary Reason for Leaving May We Contact Employer?
$
per
$
per
Y
es
N
o
Date Separated (mo/yr) List major duties 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: Number Supervised by you:
Date Employed (mo/yr) Starting Salary Ending or Current Salary Reason for Leaving May We Contact Employer?
$ per $ per
Y
es No
Date Separated (mo/yr) List major duties 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: Number Supervised by you:
Date Employed (mo/yr) Starting Salary Ending or Current Salary Reason for Leaving May We Contact Employer?
$
per
$
per
Y
es
N
o
Date Separated (mo/yr) List major duties 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:
MILITARY SERVICE
PART IV:
1. Males subject to Military Selective Service registration must certify compliance to be eligible for County Employment (G.S. 143b-421.1). If subject to
Military Service registration, certify compliance by initialing dotted line…………………………………
2. Have you ever served in the U.S. Armed Forces
?
YES NO
3. Are you a member of the Military Reserves? YES NO
4. Branch of Servic
e
5. Active Dut
y
6. Rank upon separation/discharg
______________________ From __________ To ______________ __________________________
7. Type of Separation/discharge ________________________________________________________________________
_
PART V:
YES NO
1. Have you ever submitted an application with the County of Lee?
2. Have you ever been employed by the County of Lee
? Give dates, department and your name
(
if different at that time) in answer section below.
3. Are you related by blood or marriage to any person now employed by the County of Lee
? If
"yes," give name, relationship, and department where employed in
the answer section below.
4. Have you ever been dismissed or forced to resign from any position? Give complete details in the
answer section below.
5.
Have you ever been convicted of an offense a
gainst the law or are you now under charg
es for any
offenses against the law? If your answer is "yes", explain below
. NOTE: A conviction does not
automatically mean that you cannot be considered for employment with the County.
6.
If requested and as required for employment, I agree to submit to testing for substance abuse.
7.
Check type of work you will accept:
____ Full-Time ____ Part-Time _____Temporary _____ Any of the proceeding
Space for above detailed answers. Indicate item number to which answers apply.
ITEM NO.
DETAILS
PART VI:
List three persons who are NOT related to you and who have definite knowledge of your qualifications and fitness for
the position for which you are applying. DO NOT repeat names of supervisors listed under Part III, WORK HISTORY.
NAME
ADDRESS AND PHONE NUMBER BUSINESS OR
OCCUPATION
PART VII:
DECLARATION OF APPLICANT:
I certify that I have given true 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 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
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e
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it
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opportunity and pledges that it will not practice or permit discrimination in employment on the basis of race, color, religion, sex,
national origin or disability. Moreover, the County complies with all applicable legislation prohibiting age discrimination (40-64) in
employment
The County of Lee appreciates your interest in employment. We intend to make your visit with us as pleasant as possible and to
Many persons apply each year. Thus, it is not always possible to spend as much time with each applicant as we would like.
A
FFIRMATIVE ACTION
Please review the "Equal Opportunity Pledge" at the top of this page.
This im
p
ortant
p
olic
y
reflects our dedication to the idea that all a
pp
licants and all members of the Count
y
staff must receive e
q
ual
The Count
y
's affirmative action
p
lans assure e
q
ualit
y
of o
pp
ortunist in all as
p
ects of em
p
lo
y
ment.
The County promises it does not discriminate against any applican
t
or employee because o
f
race, color, religion, sex, national origin or
disabilit
y
. Moreover
,
Count
y
p
olic
y
p
rohibits a
g
e discrimination as
p
rovided in law. S
p
ecial efforts are made to em
p
lo
y
veterans.
EMPLOYMENT STANDARDS
The County selects an applicant based on his or her qualifications and the requirements and essential functions for a particular job.
YOUR APPLICATION
Your application receives careful consideration. Work history, proven skills and other relevant factors are evaluated thoroughly.
This document is our chief source of information for referring you to departments with job openings. Normally, interviews are
arranged only after applications have been reviewed. It is not possible to interview all applicants. Therefore, it is necessary that you
clearly and completely state your interests and qualifications on your application form. Please complete it carefully. Add any
information you think may be helpful.
Please indicate the specific job or kinds of work you prefer so we may give you appropriate consideration. It is not possible to review
The Count
y has many departments and it takes time for them and Human Resources to communicate. Thus, do not be disappointed it you do
A
CTIVE APPLICATIONS
Applications remain in active status for six months following the date of application and , thereafter, in an inactive status for a period
of 18 additional months. An applicant who wishes to have an application either remain in active status beyond six months or returned
to active status after expiration of such period may have this accomplished by oral or written notification to Lee County
Administration at any time in the period up to two years from date of such application.
IF YOU ARE REFERRED
If you are selected for an interview, the Countyof Lee will contact you tomake the necessary arrangements. Selections are based
upon training, experience and demonstrated ability. During any visit with an operating department, you will learn more about specific
job opening for which you are being interviewed. Staff will talk with you to determine mutual interest.
The County of Lee supports a drug free workplace. As part of the selection process, final applicants for a permanent position shall
GETTING A JOB
Permanent Staff employees are those employed for more than six calendar months. Permanent full time staff are entitled to all the
customary County benefits for this category.
A permanent employee is considered probationary during the first six calendar months of employment.
Temporary staf
f
employees are appointed fo
r
twelve calendar months or less. They are not eligible fo
r
any insurance and benefits
p
lans and earn neither
p
aid leave nor holida
y
s.
APPLICANT LOG
The County of Lee is an Equal Opportunity / Affirmative Action Employer. The Federal Government requires us to collect and be able to produce data
pertaining to each applicant's ethnic background, citizenship and sex, as well as any disability. Please complete the following Applicant Log Information,
which will be removed from the application, retained in the County Human Resources Department and not forwarded to any employment department. In
keeping with the County's status as an Equal Opportunity / Affirmative Action Employer, this information will not be used in making any discussion affecting
employment or any personnel action following employment.
Today's Date
Name (Print or Type as on Social Security Card)
Are you a Vietnam Era Veteran?
(Vietnam Era begins August 4, 1964)
Month / Year
(Last) (First) Middle ____No _____Yes
ETHIC BACKGROUND CITIZENSHIP
PHYSICAL OR MENTAL
DISABILITY (IF ANY)
White (not Hispanic)
Origins in Europe, North Africa,
the Middle East, or the Indian
subcontinent
Resident foreign national (Alien who has been
admitted for permanent residence (must have
Alien Registration Card, Form 1-151)
Blind
Black (not Hispanic)
Origins in any of the black racial
groups
Non-resident foreign national (Alien admitted
temporarily for specific purposes and periods of
time)
Deaf
American Indian or
Alaskan Native
Origins in the original peoples of
North America
U. S. Citizen Communicative
Asian or Pacific
Islanders
Origins in the Far East,
Southeast Asia, or the Pacific
Islands
Orthopedic
Hispanic
Mexican, Puerto Rican, Cuban,
Central or South American, or
other Spanish culture or origin,
regardless or race
Other: (Specify)
Applicant's Job Interest(s): This application is in response to (please specify):
1. Newspaper Radio
2. Employment Security Commission TV
3. Personal Referral Other:
(Do not complete this secition) For Human Resources Department Use Only
County New Hire Date:_________________________ Type of Appointment ___P ___ T Department:__________________
Continuation Sheet - Application for Employment
County of Lee
Last 4 Digits of Social Security Number Last Name
Employer: Address:
Job Title: Supervisor's Name: Telephone Number: Number Supervised by you:
Date Employed (mon/yr) Starting Salary Ending or Current Salary Reason for Leaving May We Contact Employer?
$ per $ per Yes No
Date Separated (mon/yr)
List major duties 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: Number Supervised by you:
Date Employed (mon/yr) Starting Salary Ending or Current Salary Reason for Leaving May We Contact Employer?
$ per $ per
Yes No
Date Separated (mon/yr)
List major duties 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: Number Supervised by you:
Date Employed (mon/yr) Starting Salary Ending or Current Salary Reason for Leaving May We Contact Employer?
$ per $ per Yes No
Date Separated (mon/yr)
List major duties 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 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 failure to disclose relevant information, may be grounds for rejections 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
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COUNTY OF LEE APPLICATION FOR EMPLOYMENT (Lee County Government)

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Completed 18 July 2020

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