Form 107 Application For Employment
User Manual: Form-107-Application-for-Employment
Open the PDF directly: View PDF 
.
Page Count: 8
| Download | |
| Open PDF In Browser | View PDF |
Star Telephone Membership Corporation 3900 North U.S. 421 Highway Clinton, North Carolina 28328-0348 1-800-706-6538 APPLICATION FOR EMPLOYMENT Form 107 Date: ___________________ Note: Applicants applying for positions that require them to drive Cooperative vehicles must also fill out the Driver's Supplemental Application for Employment. This application will be considered only for the vacant position for which you are applying. To be considered for other vacant positions, a new application must be filed. The following information is requested in order to help us make the best possible placement within the Cooperative. All portions of this application pertaining to you must be completed. We appreciate the time you spend in filling in this application form. The Cooperative, in accordance with state and federal laws, does not discriminate on the basis of race, color, religion, sex (including pregnancy), national origin, age, disability, sickle cell or hemoglobin C trait, genetic information, or veteran status. STAR TELEPHONE MEMBERSHIP CORPORATION IS AN EQUAL OPPORTUNITY EMPLOYER. PLEASE PRINT Name: (Last) Address: (First) Telephone No.: (Street) (City) (Middle) (State) Social Security Number _____ / ____ / _____ (Zip) Alternate No.: Do you have the legal right to work in the United States? G G Yes No Are you a relative, either by blood or marriage, of any employee or Director of the Cooperative? G G Yes No Have you ever applied for a job with the Cooperative? If yes, when? G G Yes No Have you ever worked at the Cooperative before? If yes, when? G G Yes No Are you at least eighteen years of age? G G Yes No How were you referred to the Cooperative? Position for which you are applying (be specific): Salary Expected: $ per In what state or states do you possess a valid and current driver’s license? State: License No.: State: License No.: State: License No.: State: License No.: In what state or states have you ever possessed a driver’s license? State: License No.: State: License No.: State: License No.: State: License No.: Can you perform the essential functions of the job for which you are applying with or without reasonable accommodation? (See attached sheet for a list of the essential functions of the job for which you are applying.) G G Yes No If you are selected for employment, on what date can you start work? List any training or special skills you have that are relevant to the position for which you are applying. List your membership in any professional or technical organizations that are related to the job requirements of the position for which you are applying. (Exclude those that may disclose your race, color, religion, sex (including pregnancy), national origin, ancestry, age, disability, veteran status, or union affiliations.) Apart from absence for religious observation, are you available to work from 8 a.m. to 5 p.m., Monday through Friday? G G Yes No G G Yes No Q Q Yes No If not, what hours can you work? Will you work overtime if asked? G G Yes No Are you willing to work after hours call-out duty and on-call assignments? Have you ever been convicted of a felony? If yes, give details, including jurisdiction (state and county) where such conviction occurred. (Criminal convictions are not an absolute bar to employment. requirements.) They will only be considered in relation to specific job Have you ever been convicted of a power (electricity) theft or power diversion? If yes, give details, including jurisdiction (state and county) where such conviction occurred. Q Q Yes No THE FOLLOWING QUESTIONS SHOULD BE ANSWERED ONLY IF THE BOX NEXT TO THE QUESTION IS MARKED. G EDUCATION School Name Address No. of Years Attended Degree Major 9 High 9 College 9 Other 9 Courses now studying G PROFESSIONAL AND MANAGERIAL APPLICANTS ONLY List special training or noteworthy achievements. Please attach your resume. G CLERICAL AND SECRETARIAL APPLICANTS ONLY Place one check for knowledge. Place two checks for experience. _____ 10-Key _____ Internet _____ Network Software _____ A/R and/or A/P _____ Load Management _____ Payroll System _____ Amipro _____ Lotus _____ PBX System _____ Customer Service _____ Microsoft Excel _____ Personal Computer _____ Data Entry _____ Microsoft Windows _____ Proofreading _____ E-Mail _____ Microsoft Word _____ Typing ____ wpm _____ Fax Machine G TRADES, CRAFTS, AND TECHNICAL APPLICANTS ONLY Place one check for knowledge. Place two checks for experience. _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Warehousing Computer inventory methods Lay out work orders Prepare work orders Basic electricity Tree trimming Brush clearing Clearing machinery Material control Perpetual inventory Automotive maintenance Painting and bodywork on vehicles _____ _____ _____ _____ Electric and gas welding Hotline work, primary and secondary Electrical hand tools Electrical safety _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Radio communication and operation Pole inspection Load management systems Meter reading Collecting consumer accounts Handling consumer concerns Connecting and disconnecting meters Electrical mapping systems Load switching Substation construction Line construction Transformer banks Regulators, capacitators, breakers and switches Underground experience, (primary and/or secondary) EMPLOYMENT RECORD (Most recent employer first) Dates Name and Address of Employer Job Title and Brief Description of Duties Salary From: From: To: To: Supervisor: Exact Reason for Leaving May we contact them? Phone: From: From: To: To: Supervisor: May we contact them? Phone: From: From: To: To: Supervisor: May we contact them? Phone: Attach additional sheets if necessary. PERSONAL REFERENCES (Not Former Employers or Relatives) Name and Occupation Address Phone Number IMPORTANT! READ THIS: CERTIFICATION I CERTIFY THAT ALL INFORMATION PROVIDED IN SUPPORT OF MY EMPLOYMENT WITH THE COOPERATIVE INCLUDING, BUT NOT LIMITED TO, THIS APPLICATION, RESUMES, MEDICAL INFORMATION, AND INFORMATION PROVIDED BY ME DURING INTERVIEWS IS CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF RELEVANT FACTS IN SEEKING EMPLOYMENT WILL RESULT IN MY DISQUALIFICATION FROM FURTHER CONSIDERATION OR MY DISMISSAL FROM EMPLOYMENT. I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COOPERATIVE AND I UNDERSTAND THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE, AT ANY TIME AT THE OPTION OF THE COOPERATIVE OR MYSELF. I FURTHER UNDERSTAND THAT NO PERSON IS AUTHORIZED TO MAKE ANY REPRESENTATION CONTRARY TO THE ABOVE STATEMENT UNLESS SUCH REPRESENTATION IS APPROVED BY THE BOARD OF DIRECTORS AND IS EMBODIED IN A WRITTEN AGREEMENT SIGNED BY THE EXECUTIVE VICE PRESIDENT AND GENERAL MANAGER OF THE COOPERATIVE. I FURTHER UNDERSTAND THAT IF OFFERED EMPLOYMENT, I WILL BE REQUIRED TO TAKE A PHYSICAL EXAMINATION AND THAT SUCH EXAMINATION WILL INCLUDE BLOOD, BREATH, URINE, OR SALIVA TESTS TO DETERMINE THE PRESENCE OR USE OF ALCOHOL OR ILLEGAL CONTROLLED SUBSTANCES. Signature of Applicant Date ! Star Telephone Membership Corporation PO Box 348, Clinton, North Carolina 28329 (910) 564-7757 FAIR CREDIT REPORTING ACT DISCLOSURE & AUTHORIZATION DISCLOSURE In considering you as an applicant for employment or as a current employee, we may choose to secure and use information contained in either a consumer report or investigative consumer report about you obtained from a consumer reporting agency when: (1) considering your application for employment (2) making a decision whether to offer you employment, (3) deciding whether to continue your employment or (4) making other employment-related decisions directly affecting you. For explanation purposes, a "consumer reporting agency" is a person or business that, on a cooperative nonprofit basis, or for monetary fees or dues, regularly assembles or evaluates consumer credit information or other information on consumers for a person who has a legitimate business need for the information or intends to use the information for employment purposes. A "consumer report" means any written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing your eligibility for employment purposes. An "investigative consumer report" means a consumer report or portion thereof in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your neighbors, friends, or associates reported on or with others with whom you are acquainted or who may have knowledge concerning any such items of information. In the event an investigative consumer report is prepared, you may request additional disclosures regarding the nature and scope of the investigation requested as well as a written summary of your rights under the Fair Credit Reporting Act. AUTHORIZATION By your signature below, you hereby authorize us to obtain a consumer report and/or an investigative report about you in order to consider you for employment. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for us to procure consumer reports at any time during the employment period. ____________________________________________________________ (Signature) ____________________________ (Date) ____________________________________________________________ (Printed) FOR EMPLOYER'S USE ONLY Interviewed by: Date: Comments: EMPLOYMENT REFERENCE CHECK Employer Person Contacted Date Date Comments Results PERSONAL REFERENCE CHECK Person ACTION G No Action G Interview - No Position Offered Date: Position: Date Accepted: G Position Offered
Source Exif Data:
File Type : PDF File Type Extension : pdf MIME Type : application/pdf Linearized : No Page Count : 8 PDF Version : 1.4 Title : Form-107-Application-for-Employment Producer : Mac OS X 10.12.6 Quartz PDFContext Creator : Pages Create Date : 2017:09:19 13:41:53Z Modify Date : 2017:09:19 13:41:53ZEXIF Metadata provided by EXIF.tools