North Carolina State University
University Dining
NC State Student Employment Application
 

PERSONAL INFORMATION
Date 05/18/2012
First Name
MI
Last Name
Preferred Name
Street Address
City
Zip Code
State
Home Phone
Other Phone
Email address
Are you legally entitled to work in the United States? Yes No Are you currently working? Yes No
Experience: (check all that apply)
Cashier/Retail
Catering/Banquet Server/Waitress
Admin Support
Cook
Food Service Assistant/Dishwasher
Stock Clerk
Truck Driver
Maintenance Assistant
Housekeeper
Other
Position applying for:
Some positions may require a Driver's license;
do you have a valid driver's license? Yes No
Number
Date available for work
Full Time: Yes No Part Time: Yes No
Are you a full-time (minimum 12 hours) NC State student? Yes No
List hours available to work: (Be specific. Leave blank if unavailable on that day.)
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Do you have food service experience? Yes No
Do you have retail/cashier experience? Yes No
Do you have supervisory experience? Yes No
How many years?
Did University Dining, NC State University or the State of NC previously employ you? Yes No
If yes, were you temporary or permanent? Temporary Permanent
Location/Department previously worked
Are you related by blood or marriage to any person(s) employed at NC State currently? Yes No
If yes, please list the name(s), relation(s), and department(s)
If you are required to be registered by the Selective Service, please certify your compliance by your INITIALS:
Give dates of active service in the Selective Service:
Please check appropriate boxes:
I served honorably in the Armed Forces of the United States on active duty.
I have a service related disability.
I am the surviving spouse or dependent of a veteran who died from service related reasons.
I am the spouse of a disabled veteran.
Give dates of spouse's active service:

CONVICTIONS
Have you ever been convicted of any unlawful offense other than a minor traffic violation? This includes DUI/DWI, worthless check, violations of local ordinances or state statues that resulted in a fine or incarceration, misdemeanors, felonies, etc. Guilty verdicts, guilty pleas, prayers for judgment (PJC's), and "non-contest" pleas must be included unless the convictions have been expunged from your record.
Yes No
If yes, list below the date(s), county(ies), state(s) and specific crime(s).
Date County State Crime
A previous conviction will not automatically disqualify you from employment. However, failure to provide complete and accurate information is considered "falsification", and your application will be removed from consideration. If falsification occurs and you are currently employed, you may be subject to disciplinary action up to and including termination of employment. If you are unsure of your conviction history please verify prior to answering.

EDUCATION
High School attended
City
State
Did you graduate? Yes No GED
College attended
City
State
Title and level of degree earned:
Date
What was your major?
Number of Hours Completed
Type of Hours Semester Hours Quarter Hours
......................................
College attended
City
State
Title and level of degree earned:
Date
What was your major?
Number of Hours Completed
Type of Hours Semester Hours Quarter Hours

EMPLOYMENT HISTORY
Include any relevant work experience no matter how long ago it occurred. Include volunteer or military service. Account for at least the PAST 5 YEARS including periods of unemployment. Do not mark "see resume".
Current or Most Recent Position:
Employer Name
Employer Address
Supervisor's Name
Phone Number
Date hired
Date separated
Were you full-time? Yes No Are you still employed here? Yes No
What was your starting salary? per Ending salary per
Reason for Leaving?
What were your primary job duties?

PREVIOUS POSITIONS
Employer Name
Employer Address
Supervisor's Name
Phone Number
Date hired
Date separated
Were you full-time? Yes No Are you still employed here? Yes No
What was your starting salary? per Ending salary per
Reason for Leaving?
What were your primary job duties?
......................................
Employer Name
Employer Address
Supervisor's Name
Phone Number
Date hired
Date separated
Were you full-time? Yes No Are you still employed here? Yes No
What was your starting salary? per Ending salary per
Reason for Leaving?
What were your primary job duties?
......................................
Employer Name
Employer Address
Supervisor's Name
Phone Number
Date hired
Date separated
Were you full-time? Yes No Are you still employed here? Yes No
What was your starting salary? per Ending salary per
Reason for Leaving?
What were your primary job duties?
......................................
Employer Name
Employer Address
Supervisor's Name
Phone Number
Date hired
Date separated
Were you full-time? Yes No Are you still employed here? Yes No
What was your starting salary? per Ending salary per
Reason for Leaving?
What were your primary job duties?

I attest that the information I have provided on my application materials (application, resume, etc.) is to the best of my knowledge and ability, up-to-date and accurate. I authorize institutions, employers, associations, registration and licensing boards, and others to furnish whatever details are available concerning my qualifications. I authorize investigation by NC State University of all statements made by me and will not hold any parties disclosing information for this reason liable. I understand that false information or a failure to disclose relevant information may be grounds for termination, disciplinary and/or criminal action. By signing below, I certify that I have read and agree with the above statements.
I certify that I have read and agree with the above statements.
UNSIGNED AND INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED
VOLUNTARTY DEMOGRAPHIC DATA
Discrimination on the basis of race, sex, color, religion, national origin, age, disability or veteran status is prohibited at NC State University. Sex or age or absence of disability may be a bonafide occupational requirement in a small number of jobs. The University values the benefits of cultural diversity and pluralism in the academic community and welcomes all men and women of good will without regard to sexual orientation.
Gender Female Male Do Not Wish To Disclose
Are you Hispanic or Latino? Yes No
Optional Race Category:

If you identified yourself as Hispanic or Latino, you are not required to select an additional category.		   American Indian / Alaskan Native
  Asian
  Black / African American
  Do Not Wish To Disclose
  Native Hawaiian or Other Pacific Islander
  White
Date of Birth