McDowell County PD-107

WORK EXPERIENCE
DATES
EMPLOYER
POSITION TITLE
ADDRESS: (Street, City, State/Province, Zip Code)
COMPANY URL
PHONE NUMBER
SUPERVISOR
MAY WE CONTACT THIS EMPLOYER?

YesNo
HOURS PER WEEK
NUMBER OF EMPLOYEES SUPERVISED
DUTIES
REASON FOR LEAVING
DATES
EMPLOYER
POSITION TITLE
ADDRESS: (Street, City, State/Province, Zip Code)
COMPANY URL
PHONE NUMBER
SUPERVISOR
MAY WE CONTACT THIS EMPLOYER?

YesNo
HOURS PER WEEK
NUMBER OF EMPLOYEES SUPERVISED
DUTIES
REASON FOR LEAVING
DATES
EMPLOYER
POSITION TITLE
ADDRESS: (Street, City, State/Province, Zip Code)
COMPANY URL
PHONE NUMBER
SUPERVISOR
MAY WE CONTACT THIS EMPLOYER?

YesNo
HOURS PER WEEK
NUMBER OF EMPLOYEES SUPERVISED
DUTIES
REASON FOR LEAVING
*****Please use the PD107 Continuation Sheet for Additional Work Experience*****

CERTIFICATES AND LICENSES
TYPE
LICENSE NUMBER
ISSUING AGENCY

SKILLS
OFFICE SKILLS
OTHER SKILLS
LANGUAGE(S)

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 willbe 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. This information will not be forwarded to the hiring manager
What is your gender?
What is your ethnicity?
What is your date of birth?

MonthDayYear
Date
What is your age range?

MCDOWELL COUNTY DRUG SCREENING CONSENT FORM
FULL NAME*
I understand that as part of the pre-employment 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.
SIGNATURE*

Clear
FULL SOCIAL SECURITY NUMBER*
TODAY'S DATE*

MonthDayYear
Date

BACKGROUND CHECK CONSENT FORM
DATE OF BIRTH*

MonthDayYear
Date
FULL SOCIAL SECURITY NUMBER*
LEGAL PRINTED NAME*
FULL ADDRESS (ADDRESS, CITY, STATE, ZIP)*
DRIVER'S LICENSE STATE & #:*
SIGNATURE*

Clear
TODAY'S DATE*

MonthDayYear
Date

McDowell County Pre-Hire Job Reference Requirements

If you are one of our finalists for a position, Human Resources will require professional and qualitative references from your current employer, direct supervisor or previous employers before an offer may be extended. Employers often require current/former employees to sign releases to allow references to be given. It is your responsibility to ensure you have completed the required steps to allow employer(s), to provide reference to McDowell County.
APPLICANT'S PERMISSION TO REQUEST PERFORMANCE INFORMATION FROM CURRENT AND PREVIOUS EMPLOYERS
FULL LEGAL NAME*
I authorize McDowell County to request job performance information from the
organizations and individuals listed below. This information may include my suitability for re-employment with the agency; my skills, abilities, and traits as they may relate to my suitability for future employment; and the reason for my separation. I understand that I am responsible for completing any paperwork/process necessary to allow this information to be provided to McDowell County.
EMPLOYER #1*
DIRECT SUPERVISOR*
PHONE NUMBER*
EMPLOYER #2
DIRECT SUPERVISOR
PHONE NUMBER
EMPLOYER #3
DIRECT SUPERVISOR
PHONE NUMBER
PLEASE CONTACT ME PRIOR TO REQUESTING REFRERENCES FROM THE AGENCIES/PERSONS LISTED ABOVE...*

YesNo
SIGNATURE*

Clear
TODAY'S DATE*

MonthDayYear
Date
Applicants who are local or state government employees should be aware that North Carolina law allows their employers to release certain information about their job history and job performance to a prospective employer.

153A-98. Privacy of employee personnel records.

(a) Notwithstanding the provision of G.S. 132-6 or any other general law or local act concerning access to public records, personnel files of employees, former employees, or applicants for employment maintained by a county subject to inspection and may be disclosed only as provided by this section. For purposes of
this section employee’s personnel file consists of any information in any form gathered by the county with respect to the employee and, by way of illustration by not limitation, relating to their application, selection or non-selection, performance, promotions, demotions, transfers suspension and other disciplinary actions,
evaluation forms, leave, salary, and termination of employment. As used in this section, “employee” includes former employees of the county.

(b) The following information with respect to each county employee is a matter of public record.
(i) Name.
(ii) Age.
(iii) Date of original employment or appointment to the county service.
(iv) The terms of any contract by which the employee is employed whether written, oral, past and current, to the extent that the county has the written contract or a record of the oral contract in its possession.
(v) Current position.
(vi) Title.
(vii) Current salary.
(viii) Date and amount of each increase or decrease in salary with that county.
(ix) Date and type of each promotion, demotion, transfer, suspension, separation or other change in position or classification with that county.
(x) Date and general description of the reasons for each promotion within that county.
(xi) Date and type of each dismissal, suspension, or demotion for disciplinary reasons taken by the county. If disciplinary action was a dismissal, a copy of the written notice of the final decision of the county setting forth the specific acts or omissions that are the bases of the dismissal.
Should be Empty:

EMPLOYMENT APPLICATION

PERSONAL INFORMATION

DRIVER'S LICENSE:

PREFERENCES

EDUCATION

WORK EXPERIENCE

CERTIFICATES AND LICENSES

SKILLS

Agency - Wide Questions

Equal Opportunity Information

MCDOWELL COUNTY DRUG SCREENING CONSENT FORM

BACKGROUND CHECK CONSENT FORM

McDowell County Pre-Hire Job Reference Requirements

APPLICANT'S PERMISSION TO REQUEST PERFORMANCE INFORMATION FROM CURRENT AND PREVIOUS EMPLOYERS