APPLICATION FOR EMPLOYMENT

Per
Full Name
Last Four of SSN
Phone Number
Skills

Check the following skills, experience, etc. which you have:
Driver's License

Yes
Driver's License Class
Driver's License State and Number
Languages other than English

Yes
Specify languages here
Keyboarding/Typing

Yes
Specify Words Per Minute
Computer Skills

MicrosoftExcelPowerPointPublisherAccessOther
Work History
Current or Last Employer
Address
Job Title
Supervisor Name
Telephone Number
Date Employed (MM/YY)
Date Separated (MM/YY)
Full Time - Years years Full Time - Months months
Part Time - Years years Part Time - Months months
If part time, number of hours worked per week
Ending/Current Salary
Per
No. Supervised by you
Reason left or will be leaving
List major duties that demonstrate your competencies related to the position for which you are applying, in order of their importance in the job
Employer
Address
Job Title
Supervisor Name
Telephone Number
Date Employed (MM/YY)
Date Separated (MM/YY)
Full Time - Years years Full Time - Months months
Part Time - Years years Part Time - Months months
If part time, number of hours worked per week
Ending/Current Salary
Per
No. Supervised by you
Reason left or will be leaving
List major duties that demonstrate your competencies related to the position for which you are applying, in order of their importance in the job
Employer
Address
Job Title
Supervisor Name
Telephone Number
Date Employed (MM/YY)
Date Separated (MM/YY)
Full Time - Years years Full Time - Months months
Part Time - Years years Part Time - Months months
If part time, number of hours worked per week
Ending/Current Salary
Per
No. Supervised by you
Reason left or will be leaving
List major duties that demonstrate your competencies related to the position for which you are applying, in order of their importance 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. Electronic signatures are acceptable
Signature

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Date

MonthDayYear
Date

Work History – Continuation Sheet
Employer
Address
Job Title
Supervisor Name
Telephone Number
Date Employed (MM/YY)
Date Separated (MM/YY)
Full Time - Years years Full Time - Months months
Part Time - Years years Part Time - Months months
Part Time Years If part time, number of hours worked per week
Ending/Current Salary
Per
No. Supervised by you
Reason for leaving
List major duties that demonstrate your competencies related to the position for which you are applying, in order of their importance in the job
Employer
Address
Job Title
Supervisor Name
Telephone Number
Date Employed (MM/YY)
Date Separated (MM/YY)
Full Time - Years years Full Time - Months months
Part Time - Years years Part Time - Months months
Part Time Years If part time, number of hours worked per week
Ending/Current Salary
Per
No. Supervised by you
Reason for leaving
List major duties that demonstrate your competencies related to the position for which you are applying in order of their importance in the job
Employer
Address
Job Title
Supervisor Name
Telephone Number
Date Employed (MM/YY)
Date Separated (MM/YY)
Full Time - Years years Full Time - Months months
Part Time - Years years Part Time - Months months
Part Time Years If part time, number of hours worked per week
Ending/Current Salary
Per
No. Supervised by you
Reason for leaving
List major duties that demonstrate your competencies related to the position for which you are applying in order of their importance 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. Electronic signatures are acceptable
Signature

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Date

MonthDayYear
Date

ACKNOWLEDMENT AND AUTHORIZATION FOR BACKGROUN INVESTIGATION

I acknowledge receipt of the separate documents entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT, and certify that I have read and undestand both of those documents. I hereny authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by Macon County ("Compnay") at any time after reciept of this authorization and throught my employment, if applicable. To this end, I hereby authorize any law enforcement agency, administrator, state of federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by CastleBranch Corporation, 1844 Sir Tyler Drive, Wilmingron, NC 28405, 888-723-4263, www.castlebranch.com.

I understand that a "consumer report" may consiste of my driving history ("MVR") from a state motor vehicle records agency or Department of Motor Vehicles, and authorize the Company to obtain my MVR9s), which may contain personal information about me, such as my phtograph, social secuirty number, driver identifcation number, name, address, telepone number, and medical or disability information.

New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Compnay, and if such rpeort was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and recieve a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge reciept of Aritical 23-A of the New York Correct Law.

New York City applicants only: By signning the form, you further authorize the Company to provide you with a copy of your consumer report, the New York CIty Fair Chance Act Notice form, and any other documents, to the extent required by law, at the mailing address and/or email address you provide to the Company.

Minnesota applicants only: You have the right to submit a written request to the consumer reporting agency for a complete and accurate disclosure of the natire and scopy of any consumer report the Company ordered about you. The Consumer reporting agency must provide you with this disclosure within five business days after its reciept of your or the date the report was requested by the Company, whichever date is later. Please check this box if you would like to recieve a copy of a consumer report if one is obtained by the Company.

Oklahoma applicants only: Please check this box if you would like to recive a copy of a consumer report if one is obtained by the Company.

Washington State applicants only: You also have the right to requested from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Minnesota Applicants Check hereOklahoma Applicants Check here
Signature

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Date

MonthDayYear
Date

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Macon County ("the Company") may obtain information about you from a third party consumer reporting agency for employment purposes. Thus, you may be the subject of a "consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your credit history, criminal history, social secuirty verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks.

You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by CastleBranch Corporation, 1844 Sir Tyler Drive, Wilmington, NC 28405, 888-723-4263, www.castlebranch.com.
Signature

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Date

MonthDayYear
Date

Name

First NameMiddle NameLast Name
Suffix
Other Names/Maiden/Alias
Social Security Number
Date of Birth

MonthDayYear
Date
Drivers License Number
State
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Signature

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Date

MonthDayYear
Date

DRIVER’S DISCLOSURE FORM
Effective September 13, 1997, all motor vehicle records are subject to the Federal Drivers’s Privacy Protection Act (FDPPA) and General Statute 20-43.1. The FDPPA and GS 20-43.1 require that personal information in the Division of Motor Vehicles records be closed to the public. Personal information from these records may be
released to individuals or organizations that qualify under one of the fourteen (14) exceptions listed on the back of this form. These exceptions are summarised statements of permissible uses.
NAME OF DRIVER
DL CLass

ABC
Driver's License Number
State of DL
TELEPHONE
STREET ADDRESS
CITY
STATE
ZIP CODE
NAME OF COMPANY / AGENCY MACON COUNTY

By signing this form, you are granting the company access to your personal information under exception number 13 of the FDPPA and GS 20-43.1.
SIGNATURE OF DRIVER

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DATE SIGNED

MonthDayYear
Date

FEDERAL DRIVER’S PRIVACY PROTECTION ACT ENACTED BY CONGRESS AUGUST 24, 1994
Chapter 123, Section 2721 requires that personal information from the Division of Motor Vehicles’ records be disclosed to the public. This refers to photos, social security numbers, drivers license numbers, names, addresses, telephone numbers, and medical information.

General Purpose: The Division of Motor Vehicles, any officer, employee, or contractor, therefore, shall not knowingly disclose or otherwise make available to any person or entity personal information about any individual obtained by the Division in connection with a motor vehicle record.

Permissible Uses: Personal information SHALL be disclosed for use in connection with matters of:

A.Motor vehicle or driver safety and theft

B.Motor vehicle emissions

C.Motor vehicle product alterations, recalls, or advisories

D.Performance monitoring of motor vehicles and dealers by motor vehicle manufacturers

E.Removal of non-owner records from the original owner records of motor vehicle manufacturers to carry out the purposes of the Automobile Information Disclosure Act, the Motor Vehicle Information and Cost Saving Act, the National Traffic and Motor Vehicle Safety Act of 1966, the Anti-Car Theft Act of 1992, and the Clean Air Act

Exceptions:

Personal information MAY be released for the following reasons: (List qualifying number on reverse)

1. For use by any government agency, or private person or entity acting on behalf of a Federal, State, or local agency in carrying out its functions.

2. For use in matters of motor vehicle or driver safety and theft, motor vehicle emissions; motor vehicle product alterations, recalls, or advisories; performance monitoring of motor vehicles, motor vehicle parts and dealers; motor vehicle market research activities, including survey research; and removal of non-owner records from the original owner records of motor vehicle manufacturers.

3. For use in the normal course of business by a legitimate business but only:

a. To verify the accuracy of personal information

b. To obtain correct information, but only for the purposes of:

1. Preventing fraud by the individual

2. Pursuing legal remedies against the individual

3. Recovering on a debt or security interest against the individual.

4. For use in connection with any civil, criminal, administrative, or arbitral proceeding in any Federal, State, or local court or agency (includes the execution or enforcement of judgments and orders, or court orders

5. For use in research activities and statistical reports a. Personal information must not be: 1.Published 2.Redisclosed 3.Used to contact individuals

6.For use by insurance companies in connection with claims investigation, antifraud activities, rating or underwriting

7.For use in providing notice to the owners of towed or impounded vehicles

8.For use by private investigators or licensed security service

9.For use by employer to verify information regarding CDL

10. For use in connection with private toll facilities

11. For any other use if person has opportunity to refuse disclosure on DMV forms (Prohibited by NC General Statute 20-43.1)

12. For bulk surveys, marketing or solicitations (Disclosure must be accordance with NC General Statute 20 43.1)

13. For use by any requester that has obtained written consent of the individual to whom the information pertains

14. For any use specifically authorized under the law of the State that holds the record, if such use is related to the operation of a motor vehicle or public safety
Should be Empty:

APPLICATION FOR EMPLOYMENT

Availability

Jobs Applied For

Military Service

Referral Source

Education

High School

College(s)/University(s)

Graduate/Professional

Other Educational vocational school, Internships etc

Special Training

Current Professional Status

Skills

Work History

Work History – Continuation Sheet

DRIVER’S DISCLOSURE FORM

NAME OF COMPANY / AGENCY MACON COUNTY

FEDERAL DRIVER’S PRIVACY PROTECTION ACT ENACTED BY CONGRESS AUGUST 24, 1994

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