North State

North State Acceptance

Employment Application

General Information

It is the policy and intent of North State Acceptance to provide equal opportunity to all eligible applicants, and to prohibit discrimination because of race, color, religion, age, national origin, gender, veteran status, physical or mental disability unrelated to an individual’s ability to perform the job, or any other unlawful basis, in accordance with applicable law. In addition to the above, it is North State Acceptance policy and intent to provide a workplace that is comfortable, productive, safe, and free from unlawful harassment and intimidation in all phases of employment.

As a routine part of our employment process North State Acceptance may procure or have prepared an investigative consumer report to verify the information you have provided including but not limited to education, driving, criminal and employment history.

Name:_______________________________________ Date of Application:________________

Position Applying For:____________________________________________________________

I am interested in employment that is: Full-time Part-time Temporary

Street Address:

City: State: Zip:

SSN:

Day Phone: Evening Phone:

Date available to start: Wage/Salary Desired:

	Yes	No
Have you been previously employed by North State Acceptance? If yes, when and in what capacity?
Have you previously applied for employment with North State Acceptance? If yes, when and in what capacity?
Are you able to perform the essential functions of the job for which you are applying either with or without reasonable accommodation?
Do you have the legal right to work and be employed in the United States? (Proof of identity and legal authority to work in the U.S. is a condition of employment)
Are you at least eighteen years of age?
Have you been convicted of a misdemeanor or felony? If yes, please give date, place, offense and outcome: An affirmative answer will not result in automatic disqualification from employment. All facts and circumstances will be considered.

How did you hear about this position?

Newspaper Friend Walk-in Employment Agency Internet Other _______________

Education

School	Name & Address	Course of Study	Circle Year Completed				Major & Degree
High School			1	2	3	4
College			1	2	3	4
Graduate School			1	2	3	4
Bus. Or Trade School			1	2	3	4

Driver’s License

Do you have a driver’s license? Yes No
Driver’s license Number ___________________	State of issue ________ Operator Commercial (CDL) Chauffeur
Expiration date __________________
Have you had any accidents in the past three years? Yes No How Many? ______________
Have you had any moving violations during the past three years Yes No How Many? ______________

Employment History

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give the firm name. Attach additional sheets if necessary. Explain any gaps in employment.
Most recent employer	Date employed From: To:	Worked performed
Address	Supervisor
Job Title	Reason for leaving

Employer	Date employed From: To:	Worked performed
Address	Supervisor
Job Title	Reason for leaving
Employer	Date employed From: To:	Worked performed
Address	Supervisor
Job Title	Reason for leaving
Employer	Date employed From: To:	Worked performed
Address	Supervisor
Job Title	Reason for leaving
Employer	Date employed From: To:	Worked performed
Address	Supervisor
Job Title	Reason for leaving

U.S. Military History

Are you a veteran of the U.S. military service? Yes No If yes, what branch? ______________________ If yes, date entered_______________________ Date discharged________________________ If yes, please describe any special skills or training acquired while in the service:

Supervisory References

Please list below the name, telephone number and your relationship for two references. Both references must be from recent supervisors. None may be from relatives.

Name	Company	Phone Number	Relationship

References from Colleagues

Please list below the name, telephone number and your relationship for two references.

Both must be from recent colleagues who are familiar with the quality of your work. None may be from relatives.

Name	Company	Phone Number	Relationship

The Legal Stuff

Please initial each paragraph below to indicate your agreement with its terms:

_______ I understand that North State Acceptance is dedicated to the concept of personal integrity in the conduct of its business affairs and that all of its policies and practices flow from this principle. I understand and agree that if I am employed by North State Acceptance I must conduct myself in accordance with all company policies including those regarding integrity, equal employment opportunity, affirmative action, and non-harassment. Acts of unlawful harassment or discrimination by any employee are strictly prohibited and will result in disciplinary action up to and including termination of employment.

_______ I authorize a thorough investigation of my references, education, driving, criminal, employment history and other matters related to my suitability for employment. Furthermore, I authorize the references I have listed to disclose to the company any and all information related to my work performance, history and/or records without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands or liabilities arising out of or in any way related to such an investigation or disclosure.

_______ I understand that nothing contained in this application, or conveyed during the interview process or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is at-will and is for no definite period and may be terminated at any time, with or without notice and with or without cause, at my option or the option of the company. No promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by both an officer of the company and myself.

_______ I certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

Applicant’s Signature: Date: