MCC IS AN EQUAL EMPLOYMENT OPPORTUNITY EDUCATIONAL INSTITUTION.
INSTRUCTIONS FOR COMPLETING APPLICATION FORM
MONTGOMERY COMMUNITY COLLEGE
1011 PAGE STREET, TROY, NORTH CAROLINA 27371
1. TO BE CONSIDERED FOR STATE EMPLOYMENT, YOU MUST ANSWER ALL QUESTIONS AND COMPLETE ALL SECTIONS OF THIS
2. THE STATE EMPLOYES ONLY US CITIZENS OR ALIENS WHO CAN PROVIDE PROOF OF IDENTITY AND WORK AUTHORIZATION WITHIN 3
WORKING DAYS OF EMPLOYMENT.
3. MALES SUBJECT TO MILITARY SELECTIVE SERVICE REGISTRATION MUST CERTIFY COMPLIANCE TO BE ELIGIBLE FOR STATE
EMPLOYMENT (G.S. 143B-421.1). SEE AVAILABIITY BLOCK.
4. A BACKGROUND CHECK IS REQUIRED FOR ALL PROSPECTIVE EMPLOYEES. YOUR SIGNATURE IS REQUIRED IN ORDER TO OBTAIN
THIS INFORMATION. (See page 5)
WHEN COMPLETING THIS APPLICATION, PLEASE MAKE SURE YOU:
1. USE A BLACK INK PEN OR TYPEWRITER.
2. COMPLETE THE SECTION OF EQUAL OPPORTUNITY INFORMATION LISTED AT BOTTOM OF THIS PAGE.
3. GIVE COMPLETE INFORMATION ON YOUR ECUCATION AND WORK HISTORY ("SEE RESUME" IS NOT ACCEPTABLE).
4. LIST SEPARATELY EACH JOB HELD AND YOUR DUTIES FOR EACH POSITION WHEN YOU WORKED FOR ONE EMPLOYER AND HELD
MORE THAN ONE POSITION.
5. CHECK FOR ACCURACY. SIGN AND DATE YOUR APPLICATION.
NOTE: IF YOU FORGET TO COMPLETE SOME PART OF THE APPLICATION OR DO NOT INCLUDE REQUESTED
INFORMATION, YOUR APPLICATION MAY NOT BE CONSIDERED.
Thank you for your interest in Montgomery Community College. It is the goal of the College to find the best qualified people available to serve the
citizens of North Carolina. Although everyone who applies cannot be hired, your application will be given every consideration.
Equal Opportunity Information
State Government policy prohibits discrimination based on race, sex, color, creed, national origin, age or
disability. Sex or age 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 Ethnic Group
(mo) (day) (year)
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)
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
A None/Prefer not to report
B Blind or severely visually impaired
C Deaf or severely hearing impaired
D Loss or limited use of arms and/or hands
E Non-ambulatory (must use wheelchair)
F Other orthopedic impairment (including amputation,
arthritis, back injury, cerebral palsy, spina bifida, etc.)
G Respiratory impairment
H Nervous system/Neurological disorder
I Mentally restored
J Mental retardation
K Learning disability
L Others (heart disease, diabetes speech impairment)
M Other (please specify)
Applicant name: Date: