State PD-107 Application

Personal Information
Date of Application *

Month Day Year
Date
Last 4 Digits of Social Security No. *
Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County *
Home Number *
Please enter a valid phone number.
Business Number *
Please enter a valid phone number.
Do you now work for McDowell County? *

Yes No
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. *

Availability
Check the types of work you will accept: *

Permanent full-time Permanent part-time Temporary full-time Temporary part-time Any of the preceding Work involving travel 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 the counties in which you would be willing to work:
1. Type a label 2. Type a label 3. Type a label
4. Type a label 5. Type a label
Job Applied For (Enter below the specific title for the job for which you are applying. *
Vacancy Number
Referral Source
If you were referred by the Employment Security Commission (Job Service) please indicate which local office:

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 veterans preference as the spouse of a disabled veteran? *

Yes No
Give dates of your (or spouse's) qualifying active military service:
Entered: Entered Separated: Separated
Branch: Branch Rank: Rank

Work History

(include volunteer experience) Use additional sections 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:
Phone Number
Please enter a valid phone number.
No. Supervised by you:
Date Employed (mo/yr):
Date Separated (mo/yr):
Starting Salary: blanks per blank .
Ending or Current Salary: blanks per blank .
Reason for Leaving:
May we contact employer?

Yes No
Full Time: (Years, months)
Part Time: (Years, months)
If part time, number of hours worked per week:
List major duties that demonstrate your competencies related to the position for which you are applying in order of their important in the job:

Additional Work History
Employer:
Address:
Job Title:
Supervisor's Name:
Phone Number
Please enter a valid phone number.
No. Supervised by you:
Date Employed (mo/yr):
Date Separated (mo/yr):
Starting Salary: blanks per blank .
Ending or Current Salary: blanks per blank .
Reason for Leaving:
Full Time: (Years, months)
Part Time: (Years, months)
If part time, number of hours worked per week:
List major duties that demonstrate your competencies related to the position for which you are applying in order of their important in the job:

Additional Work History
Employer:
Address:
Job Title:
Supervisor's Name:
Phone Number
Please enter a valid phone number.
No. Supervised by you:
Date Employed (mo/yr):
Date Separated (mo/yr):
Starting Salary: blanks per blank .
Ending or Current Salary: blanks per blank .
Reason for Leaving:
Full Time: (Years, months)
Part Time: (Years, months)
If part time, number of hours worked per week:
List major duties that demonstrate your competencies related to the position for which you are applying in order of their important in the job:

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

Unsigned applications will not be processed
Signature *

Clear
Date of Application *

Month Day Year
Date

References

List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

	Name	Title	Relationship	Telephone with Area Code	Number of Years Known
Reference #1
Reference #2
Reference #3

Drug Screening Consent Through Urinalysis
I, Full Legal Name*understand that as part of the preemployment process I am required to submit to a urinalysis drug screening. This is in accordance with the policy of McDowell County to maintain a workforce that is free of illegal drug abuse.

I do hereby voluntarily consent to the sampling and submission for testing of my urine for the purpose of screening for the presence of illegal drugs and/or an abusive level of prescribed medication. I understand that a positive result from this screening may be a condition of employment and may bar me from employment with McDowell County for a period of one year.

I authorize disclosure of the drug screen results by and between the testing
laboratory, Medical Review Officer and the employing agency.
Full Legal Name *
Social Security Number *
Signature *

Clear
Date *

Month Day Year
Date

Background Check Consent Form

Wolfe Reality Check Consumer Report and Investigative Consumer Report Disclosure (For Employment Purposes)
Part 1 - Authorization for release of information (for employment purposes)

I hearby authorize Agency to receive information and disclose such information to its customers for the purpose of making a determination as to my eligibility for employment, promotion, retention or other lawful purpose. If hired or contracted, I authorize Agency and to retain this document on file to as as ongoing authorization for the procurement and possession of Reports at any time during my employment or contact period. I full release Agency and Suppliers from all claims of damages related to the investigation of my background and provision of information as set forth in this disclosure and authorization. I agree that information in Agency's possession may be supplied by Agency for legally permissible purposes; provided, such information will not include the Drug and Alcohol information set forth above, unless I have given a separated specific consent for Agency to share such information.

By signing below, I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this disclosure and authorization for release; (iii) prior to signing, I was given an opportunity to ask questions and to have those questions answered to my satisfaction; (iv) I execute the authorization voluntarily and with the knowledge that the informatio nobtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; (vi) I authorize Agency and any person or entity contacted by Agency to furnish the above mentioned information; and (vii) facsimile or photographic copies of this authorization are as valid as the original.

I understand that if I do not consent, any offer of my employment or contract will be withdrawn. If hired failure to cooperate with you or Agency regarding a current or future report will be cause to terminate my employment or contract.
Legal Printed Name *
Address *
Social Security Number *
Date of birth *

Month Day Year
Date
Driver's License State and Number *
Signature *

Clear
Today's Date *

Month Day Year
Date

Document Upload

Please upload any necessary documents you would like provide alongside your completed Application for Employment. This may include resumes, transcripts, certifications, etc.
File Upload

Cancel of
Should be Empty:

	Name & Location	Dates Attended (mo/yr) From: To:	Grad? Y/N	S/Q Hrs.	Major/Minor Course Work	Type of Degree Received
High School
College
Graduate
Other Educational, vocational school, internships, etc.

Application for Employment

INSTRUCTIONS TO APPLICANTS

Equal Opportunity Information

Personal Information

Availability

Military Service

Education

Skills

Work History

Additional Work History

Additional Work History

References

Drug Screening Consent Through Urinalysis

Background Check Consent Form

Document Upload