Revised Feb 2020
INSTRUCTIONS:
To be considered for NC State Government employment, you must answer all questions (unless listed as optional) and
complete all sections of this application form.
The State of North Carolina employs only US citizens or foreign nationals who can provide proof of identity and work
authorization within 3 working days of employment. Males subject to military selective service registration must certify
compliance to be eligible for state employment (G.S. 143b-421.1). See availability block.
When completing this application make sure you:
Complete the equal opportunity information section.
Apply for one vacancy per application.
If you are a RIF applicant with priority- please check the appropriate box.
Give complete information on your education and work history (“see resume” is not acceptable).
List separately each job held and your duties for each position when you worked for one employer
and held more than one position. Use a continuation sheet, PD 107-A, if needed.
As you describe your work history, make sure you highlight your competencies (knowledge, skills,
abilities and work behaviors) which demonstrate your qualifications for the position for which you
are applying.
Provide only the last four digits of your social security number.
Check for accuracy, sign and date your application.
Thank you for your interest in employment with the State of North Carolina. North Carolina hires the most qualified
people available to serve its citizens. Although everyone who applies cannot be hired, each application will be given
consideration based on its competitiveness compared to other applications received.
PD 107 (REV Feb 2020)
Equal Opportunity Information
State Government policy prohibits discrimination based on race, sex, color, creed, national origin, age, genetic information or
disability. Sex, age or absence of disability is a bona fide occupational qualification in a small number of State jobs. The information
requested below will not affect you as an applicant and is not forwarded to the hiring manager. Its sole use will be to see how well
our recruitment efforts are reaching all segments of the population. Answering the ethnicity question is optional. Birth date is required
for correct input by our technicians of paper application content into our electronic application system, where birthdate is required in
order to save the application.
1. White (Non-Hispanic/Latino)
2. Black or African American (Non-Hispanic/Latino)
3. Asian
4. American Indian or Alaskan Native
5. Native Hawaiian or Other Pacific Islander
6. Two or More Races (Non-Hispanic/Latino)
7. Hispanic/Latino
APPLICATION FOR EMPLOYMENT
State of North Carolina
Ethnicity:
Birthdate (required):
Month__________ Day___ Year ______
Disability:
Yes, I have a disability (or
previously had a disability)
No, I don’t have a disability
I don’t wish to answer
Gender (required):
Male
Female
Revised Feb 2020
APPLICATION FOR EMPLOYMENT
STATE OF
NORTH CAROLINA
Last 4 digits of Social Security No.
Last Name
First Name
Address (Street number and name)
City
State
Zip Code
Phone number where you can be reached
Email Address
Availability
Do you now work
for the State of NC?
YES NO
Are you a layoff candidate with the State of N.C. eligible for RIF priority reemployment
consideration as described by GS 126? YES NO Notification Date:
Are you related by blood or marriage to any person now working for the State? YES NO
If yes, give name, relationship to you and the agency where employed.
If subject to Military Selective
Service registration, certify
compliance by initialing dotted line
.......................................................
...............................
Military Service
Have you served honorably in the Armed Forces of the United States on active duty for reasons other than training? YES NO
Do you wish to declare a service-connected disability? YES NO
At the time of this application, are you the surviving spouse or dependent of a deceased veteran who died from service-related reasons? YES NO
Do you wish to declare eligibility for veteran’s preference as the spouse of a disabled veteran? YES NO
Give dates of your (or spouse’s) qualifying active military service:
Entered: Separated: Branch: Rank
AGENCY USE ONLY: ELIGIBILITY FOR VETERAN’S PREFERENCE: YES NO
CHECK the types of work you will accept: 1. Permanent full-time 2. Permanent part-time 3. Temporary full-time 4. Temporary part-time
5. Any of the preceding 6. Work involving Travel 7. Shift or Split Shift Work
If you are not available for work now, enter the earliest date you could begin work (mo./day/yr.)
Will you accept work anywhere in N.C.? YES NO (If no, list below the counties in which you would be willing to work.)
1. 2. 3. 4. 5.
Job Applied For
Enter below the specific title and vacancy number of the job for which you are applying.
Job Title: Vacancy Number:
Referral Source
Please indicate your referral source:
If you were referred by NC Workforce Solutions please indicate which local office
:
Education
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
Under S/Q Hrs., list the hours of credit received and if they were semester (S) or quarter (Q) hours.
Schools Name and Location
Dates Attended
(mo./yr.) From: To:
Grad? S/Q Hrs.
Major/Minor Course Work
Type of Degree
Received
High School
YES
NO
College(s)
University (s)
YES
NO
Graduate or
Professional
YES
NO
Other educational,
vocational school,
internships, etc.
YES
NO
Special training programs and seminars you have completed in the last five years (list):
If the job(s) applied for calls for specific courses, indicate those courses taken and credits received:
Current professional status: (List fields of work for which you have been registered)
Registration: State: No.
Registration: State: No.
DO NOT COMPLETE THIS BLOCK
DEGREES AND PROFESSIONAL CREDENTIALS
Have been verified
Will be verified within 90 days (G.S. 126-30)
Person Responsible:
Revised Feb 2020
Other Licenses and certifications, including Driver License and State, if any (List, giving dates and sources of issuance):
Have you ever been convicted of an offense against the law other than a minor traffic violation? (A conviction does not mean you cannot be hired. The offense and
how recently you were convicted will be evaluated in relation to the job for which you are applying.) YES NO (If yes, explain fully on an
additional sheet.)
WORK HISTORY
(include volunteer experience) Use additional sheets if necessary. As you describe your work history experiences, make sure you highlight your
competencies which demonstrate your qualifications for the position for which you are applying.
Current or Last Employer: Address:
Job Title:
Supervisor’s Name
Telephone Number:
No. Supervised by you:
Date Employed (mo./yr.)
Supervisor's e-mail:
Reason for Leaving
May We Contact Employer
YES NO
Date Separated (mo./yr.)
List major duties that demonstrate your competencies related to the position for which you are applying 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
No. Supervised by you:
Date Employed (mo./yr.)
Supervisor's e-mail
Reason for Leaving
Date Separated (mo./yr.)
List major duties that demonstrate your competencies related to the position for which you are applying 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
No. Supervised by you:
Date Employed (mo./yr.)
Supervisor's e-mail
Reason for Leaving
Date Separated (mo./yr.)
List major duties that demonstrate your competencies related to the position for which you are applying 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, accurate 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 a 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
click to sign
signature
click to edit
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