Employment Application Form
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1
2Any person offered a County position
Submit by U.S. Mail, FAX or Email:
will be required to take a Drug Test.
EMPLOYMENT APPLICATION
Human Resources Department
A physical will be required of all who
1 3 East Canal Street
are employed by the County.
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
Sumter, SC 29150
Please Print in ink or type
Prospective employees will receive
(803) 774-2827 FAX
consideration without discrimination
because of race, creed, color, sex,
age, national origin or disability.
Date:____________________________
Position applying for:_______________________________________
Department:_________________________
PERSONAL INFORMATION
Name
___________________________________________________________________________________
___________________________
Social Security Number
First
Middle
Las t
Present Address_________________________________________________________________________________________________________________________
Street
City
State
Zip Code
Previous Address________________________________________________________________________________________________________________________
Street
City
State
Zip Code
Phone Number (Day)___________________________________ (Evening)__________________________________ (Other)_________________________________
Are you a current Sumter County employee or
Yes
have you worked for Sumter County in the past?
No
If so, when?______________________ What Department?____________________________________
Your name when employed
(if different from present)
__________________________________
_____________________________________________________________________________________________________
Yes
Do you have a valid
No
driver’s license?
License No.
State
Expiration Date
Restrictions
_____________________________________________________________________________________________________
Yes
Do you have a valid
CDL?
No
License No.
State
Expiration Date
Restrictions
Misdemeanor
Have you been convicted of a:
Felony
No
No
Yes
Yes
If yes, please
explain and give dates:______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Have you ever been fired or asked to resign from a job?
Yes
No
If yes, give date, name and address of employer, and reason
__________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
(A firing or forced resignation does not automatically mean that you cannot be employed. The circumstances, time elapsed, and recent employment record will be
considered. However, failure to be completely honest and accurate about such circumstances may cause your application to be disqualified for employment.)
EDUCATION HISTORY
High School
Highest Grade
City and State:________________________
attended:_________________________________________
Completed:______________
Yes
Do you have a high school diploma or GED?
No
Date Received:___________________
Dates Attended
Mo/Yr
From
To
Degree or
Degree Completed
Major and Minor
NAME AND ADDRESS
Mo/Yr
Mo/Yr
Degree Pending
Certificate
(B.A. etc.) or Certificate
Fields of Study
College
Graduate Work
Other (i.e., business, technical, military, etc.)
Please list professional memberships, certificates, licenses, honors, fellowships, etc.____________________________________________________________________
_________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
This information will NOT be used for making employment decisions, and will NOT be kept with your application for employment. It is needed to analyze and assure compliance with State
and Federal Equal Employment Opportunity laws, and to meet reporting requirements.
CHECK APPROPRIATE BLOCKS FOR THE FOLLOWING: Date of Birth:___________________________________________________ Martial Staus:___________________________
Male
Are you
Yes
DEFINITION OF DISABLED: “Disabled person” means any person who has a physical or mental impairment which substantially
disabled?
limits one or more major life activities, has a record of such an impairment, or is regarded as having such an impairment.
No
Female
White (includes persons of Arabian descent)
Racial or ethnic group
Black (includes Jamaicans, Bahamians, and other Caribbeans of Africa but not Hispanic or Arabian descent)
with which you ifentify.
Hispanic (includes persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish origin or culture)
(Check ONLY one.)
Asian American (includes Pakistanis, Indians and Pacific Islanders)
American Indian (includes Alaskan natives)
From a relative/friend
The following information will help us to learn of the most effective way
From a Sumter County employee
Sumter County Website
of informing interested persons of the job opportunities with Sumter
Other (please specifiy)______________________________________
County. Please check ONE of the following as to how you learned of
employment opportunties with Sumter County.
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Parent category: Business