NC State: CALS NC Agricultural Research Service

North Carolina State University - University Field Laboratories

Application for Student Temporary Employment

Directions: (1) Fill out form; (2) Print form; (3) SIGN FORM at bottom; and, (4) Fax or mail form to the appropriate Field Laboratory Superintendent

Date

Social Security Number

Last NameFirst Name

Home Phone:Business Phone:

Local Address

Permanent Address if different from local

Type of Job Applying for:

Specify Field Laboratory

Note: Disclosure of your social Security Number as an applicant is voluntary. However, should you be employed, disclosure is mandatory to comply with Federal Social Security Regulation No. 4 Subpart M, Section 404.1242

GENERAL INFORMATION
Are you now, or have you ever, been employed by the State of North Carolina or NC State University?
	No Yes
If YES, list dates and names used (if different from above)


Have you ever been convicted of an unlawful offense other than a minor traffic violation?
	No Yes If YES, please explain.
A YES will not automatically disqualify you.


Do you have a valid Driver's License?
	No Yes --Number and State


If under 18 years of age, do you have a work permit?
	No Yes Not Applicable

Are you related by blood or marriage to any person(s) currently employed by North Carolina State University?
	No Yes
If YES, list name, relationship and department

MILITARY SERVICE

Are you registered with the Selective Service?
	No Yes Not Required

Have you served honorably in the Armed Forces of the United States on active duty for reasons other than training?
	No Yes

Do you have a service-related disability that you wish to report? (voluntary)
	No Yes
	If YES, list service-related disability

Are you the surviving spouse or dependent of a deceased veteran who died from service-related reason?
	No Yes

Are you the spouse of a disabled veteran?
	NO YES
Give dates of your (or spouses') qualifying active military service:
	Entered Separated

Availability - Please note hours available for work each day (Example 8AM - 5PM):

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

EDUCATION/SKILLS

Completed high school No Yes IF YES, When and where

College Graduate No Yes; IF YES-When

Trade or Other Certification

EMPLOYMENT HISTORY
Present	Start Date

Company Name

Supervisor Telephone

Address

Responsibilities/Duties

PREVIOUS
Start Date	End Date

Company Name

Supervisor Telephone

Address

Responsibilities/Duties

Start Date

End Date

Company Name

Supervisor Telephone

Address

Start Date

Responsibilities/Duties

I certify that the information I have supplied is true

Signature:

This application will be used only for reference within NC State University - University Field Laboratories. Our acceptance of this application does not indicate the availability of a position. You will be contacted to arrange an interview if your credentials are suitable for an open position.

NONDISCRIMINATION POLICY

North Carolina State University is dedicated to equality of opportunity within its community, Accordingly North Carolina State University does not practice or condone discrimination in any form, against students, employees, or applicants or the grounds of race, color national origin, religion, sex, age or handicap. North Carolina State University commits itself to positive action to secure equal opportunity regardless of those characteristics.

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This page was last updated on 3/21/2001 by webmaster