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
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 fully
answer all questions on your application accurately. Give complete information on
your education and work history.
EDUCATION OR WORK HISTORY.)
(DO NOT WRITE "SEE RESUME" UNDER
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 Opportunity Employer.
DATE:
POSITION(S) APPLIED FOR: 1.
2.
3.
NAME:
(Last)
(First)
(MI)
LEE COUNTY HUMAN RESOURCES
(919) 718-4615
(919) 718-4628 (Fax)
P.O. Box 1968 - 408 Summit Drive
Sanford, North Carolina 27331
(M/D/YYYY)
Please note, yellow fields indicate required.
Any application that is missing required
fields will be considered invalid and not
accepted. When you are finished filling out
the application and you click submit, this
document will need to access your email
program, please allow it to do so or the
document may not be recieved by HR.
PERSONAL DATA
PART I:
1. Name.
(Last)
(First)
(Middle Initial)
2. Phone Number:
Office/Cell:
Home:
3. Last Four Digits of SS #:
4. Address of Residence:
(Number and Street or Route)
(County)
(City)
(State)
(Zip Code)
5. Email Address:
EDUCATION AND TRAINING
PART II:
Mark highest grade completed:
GRADUATE SCHOOL
COLLEGE
DATES ATTENDED
MAJOR OR
TYPE OF
DIPLOMA /
From
GRADUATE
To MINOR FIELD
S/Q
Mo. Yr.
Mo.Yr.
OF STUDY
DEGREE
(Y/N)
HOURS
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
Adding machine/Calculator
Number and State
CDL
Word Processing Skills
Computer Skills
Typing (Specify WPM)
Legal transcription
Medical transcription
Sign language
Foreign language
Braille Skills
Other
Number and State
( )
( )
TYPE OF
SCHOOL
NAME AND LOCATION OF SCHOOL
HIGH SCHOOL
COLLEGE OR
UNIVERSITY
TECHNICAL
INSTITUTIONS OR
SCHOOLS
OTHER BUSINESS
TRADE, MILITARY,
ETC.
1
2
3
4
5
6
7
8
9
10
11
12
GED
1
2
3
4
1
2
3
4
1 2 3 4 5 6 7 8 9 10 11 12
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 an 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
yes
per
$
NO
List major duties In order of their Importance in the job:
If part time, number of
hours worked per week
Address:Employer:
Job Title:
Supervisors Name:
Telephone Number:
Number Supervised by you:
Starling Salary
Date Employed (mo/yr)
Ending or Current Salary
Reason for Leaving:
May We Contact Employer?
per
No
Yes
per
$ $
List major duties In order of their importance In the job:
If part time, number of
hours
worked per week:
Address
Employer:
Supervisor's Name:
Job Title:
Telephone Number: Number Supervised by you:
Starting Salary
Date Employed (mo/yr)
Ending or Current Salary
Reason for Leaving:
May We Contact Employer?
No
per
per
$
YES
$
Date Separated (mo/yr)
List major duties In order of their Importance In the job:
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?
3. Are you a member of the Military Reserves?
YES
NO
YES
NO
4. Branch of Service
5. Active Duty
6. Rank upon separation/discharge
From
TO
7. Type of Separation/Discharge:
$
Date Separated (mo/yr)
Date Separated (mo/yr)
Full time
Years
Months
Part time
Years
Months
Full time
Years
Months
Part time
Years
Months
Full time
Years
Months
Part time
Years
Months
PART V:
Check type of work you will accept:
Part-Time
7.
Full-Time
Temporary
Any of the proceeding
Space for above detailed answers. Indicate item number to which answers apply.
PART VI:
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).
Date
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 against the law or are you now under charges
for any offense 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?
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
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.
Signature of applicant (unsigned applications will not be processed)
ITEM NO.
DETAILS
NAME
ADDRESS AND PHONE NUMBER
BUSINESS OR
OCCUPATION
If submitting this application online, signature is not necessary and application will be signed
upon arrival if individual is called for an interview
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
yes
per
$
NO
List major duties In order of their Importance in the job:
If part time, number of
hours worked per week
Address:Employer:
Job Title:
Supervisors Name:
Telephone Number:
Number Supervised by you:
Starling Salary
Date Employed (mo/yr)
Ending or Current Salary
Reason for Leaving:
May We Contact Employer?
per
No
Yes
per
$ $
List major duties In order of their importance In the job:
If part time, number of
hours
worked per week:
Address
Employer:
Supervisor's Name:
Job Title:
Telephone Number: Number Supervised by you:
Starting Salary
Date Employed (mo/yr)
Ending or Current Salary
Reason for Leaving:
May We Contact Employer?
No
per
per
$
YES
$
Date Separated (mo/yr)
List major duties In order of their Importance In the job:
If part time, number of
hours worked per week:
$
Date Separated (mo/yr)
Date Separated (mo/yr)
County of Lee
Last 4 of Social Security Number
Last Name
Continuation Sheet - Application for Employment
I certify that I have given true and complete information on this form to the bes t 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).
Date
Signature of applicant (unsigned applications will not be processed)
Full time
Years
Months
Part time
Years
Months
Full time
Years
Months
Part time
Years
Months
Full time
Years
Months
Part time
Years
Months
If submitting this application online, signature is not necessary and application will be signed
upon arrival if individual is called for an interview
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
as any disability.
Please complete the following Applicant Log Information
pertaining to each applicant's ethnic background, citizenship and sex, as well
which will be removed from the application, retained in the County Human Resources Department and not forwarded to any employment department. In
will not be used in making any discussion affecting
keeping with the County's status as an Equal Opportunity /Affirmative Action Employer, this information
employment
or any personnel action following employment,
Are you a Vietnam Era Veteran?
(Vietnam Era begins August 4, 1964)
ETHNIC BACKGROUND CITIZENSHIP
PHYSICAL OR MENTAL
DISABILITY (IF ANY)
Resident
has been
Origins in Europe, North Africa,
foreign national (Allen who
admitted for permanent residence (must have
Alien Registration Card, Form 1-151)
the Middle East, or the Indian subcontinent
Blind
White (not Hispanic)
Non-resident foreign national (Alien admitted
and periods of
temporarily for specific purposes
Origins in any of the black racial groups
Black (not Hispanic)
Deaf
time)
Origins in the original peoples of
North America
American Indian or
Communicative
U. S. Citizen
Alaskan
Native
Far East,
Origins in the
Asian or Pacific
Southeast Asia, or the Pacific
Islanders
Islands
Orthopedic
Mexican, Puerto Rican, Cuban,
Central or South American, or
other Spanish culture or origin,
regardless or race
Other. (Specify)
Hispanic
Applicant's Job Interest(s):
This application Is in response to (please specify):
1.
Newspaper
Radio
2.
TV
Employment Security Commission
3.
Personal Referral
Other:
(Do not complete this section) For Human Resources Department Use Only
P
T Department:
Type of Appointment
County New Hire Date:
Today's Date
Name (Print or Type as on Social Security Card)
Month / Year
(First)
Middle
(Last)
No
Yes
N
Sex:
Male
Female
APPLICATION PROCESS
EQUAL OPPORTUNITY
It is the policy of the County to maintain a systematic, consistent recruitment program, to promote equal employment opportunities, and to identify and attract
the most qualified applicants for employment with Lee County. Selection decisions are made without regard to race, color, religion, sex, national origin, political
affiliation, non-disqualifying disability, age or status as a Vietnam-era or special disabled veteran in accordance with applicable federal laws.
EMPLOYMENT STANDARDS
The County selects an applicant based on his or her qualifications
for a particular job,
and the requirements and essential functions
The County employs only U.S. citizens or aliens who
can provide proof of identity and work authorization within three (3) working days of employment.
YOUR APPLICATION
should be typed or completed in black ink only.
Applications
Your application will be reviewed carefully and work history, proven skills and other relevant factors will be evaluated thoroughly.
This document is our chief source of info
rmation for referring you to departments with job openings. Normally, interviews are arranged only after applications
Therefore, it is necessary that you clearly and completely state your interests and qualifications
have been reviewed. It is not possible to interview all applicants.
form. Please complete this form carefully and add any Information you think may be helpful.
on your application
review each application in
It is not possible to
appropriate consideration.
Please indicate the specific job or kinds of work you prefer so we may give you
connection with all position openings.
fail to complete all parts
of the application or leave out requested information, your application may not be considered.
If you
ACTIVE 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.
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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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