Form 107 Application For Employment

User Manual: Form-107-Application-for-Employment

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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) (First) (Middle)
Address: Telephone No.:
(Street)
Alternate No.:
(City) (State) (Zip)
Social Security Number _____ / ____ / _____ Do you have the legal right to work in the United States? G Yes
G No
How were you referred to the Cooperative?
Are you a relative, either by blood or marriage, of any employee or G Yes
Director of the Cooperative? G No
Have you ever applied for a job with the Cooperative? G Yes
If yes, when? G No
Have you ever worked at the Cooperative before? G Yes
If yes, when? G No
Are you at least eighteen years of age? G Yes
G No
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 G Yes
with or without reasonable accommodation? G No
(See attached sheet for a list of the essential functions of the job for which you are applying.)
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., G Yes
Monday through Friday? G No
If not, what hours can you work?
Will you work overtime if asked? G Yes Are you willing to work after hours call-out duty G Yes
G No and on-call assignments? G No
Have you ever been convicted of a felony? Q Yes
If yes, give details, including jurisdiction (state and county) where such conviction occurred. Q No
(Criminal convictions are not an absolute bar to employment. They will only be considered in relation to specific job
requirements.)
Have you ever been convicted of a power (electricity) theft or power diversion? Q Yes
If yes, give details, including jurisdiction (state and county) where such conviction occurred. Q No
THE FOLLOWING QUESTIONS SHOULD BE ANSWERED ONLY IF THE BOX NEXT TO THE QUESTION IS
MARKED.
G EDUCATION
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.
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
School
Name
Address
No. of Years
Attended
Degree
Major
9 High
9 College
9 Other
9 Courses now studying
_____
_____
Internet
_____
Network Software
_____
_____
Load Management
_____
Payroll System
_____
_____
Lotus
_____
PBX System
_____
_____
Microsoft Excel
_____
Personal Computer
_____
_____
Microsoft Windows
_____
Proofreading
_____
_____
Microsoft Word
_____
Typing ____ wpm
_____
_____ 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)
Attach additional sheets if necessary.
PERSONAL REFERENCES (Not Former Employers or Relatives)
Name and Occupation Address Phone Number
Dates
Name and Address of
Employer
Job Title and Brief
Description of Duties
Salary
Exact Reason for
Leaving
From:
From:
To:
To:
Supervisor:
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:
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 Results
PERSONAL REFERENCE CHECK
Person Date Comments
ACTION
G No Action G Interview - No Position Offered G Position Offered
Date:
Position:
Date Accepted:

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