List the names of three (3) individuals, other than relatives, we may contact for references. Two (2) of the reference
sources should be job-related.
1. Name _________________________ Address ______________________________ Telephone _____________
2. Name _________________________ Address ______________________________ Telephone_____________
3. Name _________________________ Address ______________________________ Telephone _____________
Declaration of Applicant
This application does not guarantee a position in the work-study program. If your Pell Grant is terminated your work-
study position will be terminated as well. Student placement is based on funding and eligibility.
I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the foregoing statements
and answers to questions. I am aware that should an investigation disclose any misrepresentation, omission, or
falsification, my application may be rejected, or if already employed, my employment may be terminated.
I understand that North Carolina is an employment at will state. Although it is desirable for employees of Nash
Community College to form long-standing employment relationships with the College, either the employee or the
College may terminate the relationship at any time, for any reason, with or without notice. Neither the College policies
or practices nor its employee procedures are intended to alter an employee's at will relationship.
I permit Nash Community College to examine my references, record of employment, education record, and any other
information I have provided. I authorize the references I have listed to disclose any information related to my work
record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I
release Nash Community College, my former employers & all other persons from any & all claims, demands or
liabilities arising out of or in any way related to such examination or revelation.
Print Full Name
Your interest in Work-Study at Nash Community College is very much appreciated. The college wants to
find the best qualified people available. Although everyone who applies cannot be hired, your application
will be given every consideration. Thank you for offering your services to Nash Community College.
Nash Community College does not discriminate on the basis of race, color, national origin, sex, disability,
or age in its programs and activities. The following have been designated to handle inquiries regarding
the non-discrimination policies:
Lindsay Stokes Michelle Noyes
Director of Counseling & Disability Services Director of Human Resources
522 North Old Carriage Road 522 North Old Carriage Road
Rocky Mount, NC 27804 Rocky Mount, NC 27804
Office Use Only
GPA ______ Enrollment Status New ___ Returning ___
Credit Hours: Fall ______ Spring ______ Summer _____
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