Fillable STATE OF NORTH CAROLINA (Jackson County)

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STATE OF NORTH CAROLINA (Jackson County)

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PD 107 A (Rev April 2019) Continuation Sheet -- North Carolina State Government Application for Employment
STATE OF NORTH CAROLINA
An Equal Opportunity/Affirmative Action Employer
Last 4 digits of Social Security No. Last Name
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 This Employer
YES NO
Date Separated (mo./yr.)
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
May We Contact This Employer
YES NO
Date Separated (mo./yr.)
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
May We Contact This Employer
YES NO
Date Separated (mo./yr.)
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
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STATE OF NORTH CAROLINA (Jackson County)

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Completed 14 December 2020

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