STATE OF SOUTH CAROLINA
EMPLOYMENT APPLICATION
Please carefully read the following information:
In addition to evaluating you for the position for which you are applying, the following questions will provide us with statistics needed to evaluate our recruitment
program, as well as to prepare statistical reports required by Federal, State and local agencies.
Have you ever been convicted of a criminal offense? Yes No
Note: Omit minor vehicle violations and any offense committed before your 17
th
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.
If yes, please list charge(s) ___________________________________________________________________________________________________________
Where Convicted ____________________________________________________ Date _____________ Disposition/Status ____________________________
Are you currently employed by the State of South Carolina? Yes No If yes, which agency? _________________________________________________
Do you have any relatives employed with the State of South Carolina? Yes No If yes, please provide name(s), relationship, and agency below.
Name ____________________________________ Relationship ______________________ Agency ______________________________________________
Name ____________________________________ Relationship ______________________ Agency ______________________________________________
Have you ever been terminated or forced to resign from any job? Yes No If yes, please explain below.
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Will you need reasonable accommodations to participate in the selection procedures (e.g., interview, written tests, or job demonstration)? Yes No
If yes, contact the human resources office of the agency for which you are applying.
State agencies are actively supporting the Family Independence Act by hiring welfare and food stamp recipients for certain jobs. Are you currently receiving AFDC
benefits or food stamps? Yes No
Gender: Female Male Date of birth: ______ / _______ / ________ Social security number: _______ - ______ - _______
Ethnicity: American Indian / Alaskan Native Asian / Pacific Islander White / Non-Hispanic Black / Non-Hispanic Hispanic
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 employees of the State of South Carolina
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 any personnel record deemed necessary. In addition, I consent to authorize
appropriate officers, agents and employees of the State to make inquiries of third parties. I further release the organization, educational entity, present and former
employers, law enforcement organization, 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 _______________________________
Give the name, address, and phone number of two people, not relatives, who are familiar with your work.
Name ____________________________________________Address ___________________________________________________ Phone ____________________
Name ____________________________________________Address ___________________________________________________ Phone ____________________
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