AN EQUAL OPPORTUNITY EMPLOYER
Is there a minimum salary you will accept? ¨ YES ¨ NO IF YES: $ PER
What is the earliest date you could begin work?
Do you possess a valid driver’s license?
¨ YES ¨ NO IF YES, PLEASE PROVIDE INFORMATION BELOW
STATE NUMBER EXPIRATION DATE CLASS ¨ A ¨ B ¨ C ¨ D ¨ E ¨ F
Do you have any relatives employed with the State of South Carolina? ¨ YES ¨ NO IF YES, PLEASE PROVIDE NAMES BELOW:
NAME RELATION AGENCY
NAME RELATION AGENCY
Have you ever been convicted of a criminal offense? ¨ YES ¨ NO 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.
WHERE CONVICTED DATE DISPOSITION/STATUS
Have you ever been terminated or forced to resign from any job? ¨ YES ¨ NO IF YES, PLEASE EXPLAIN
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:
Are you legally authorized to work in the United States?
¨ YES ¨ NO
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
South Carolina Governor’s School for Science & Mathematics (GSSM) 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 GSSM to make inquiries of third parties such as credit bureaus. I further release the organization, educational entity, present and former employers,
law enforcement organizations, 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
