OPC Area Program
Online Employment Application
CONTACT INFORMATION
Social Security Number:
(*Optional) 		Date of Application:
 
Last Name:
 First Name:
 Middle Name:
Address (Street Number and Name):
 City:
 State:
Zip Code:
 Phone:
 Best Time to Call You:
Email:    
AVAILABILITY
Are you related to any person now working for OPC?

Yes

If yes, give name, relationship to you and the department/program to which individual is assigned:
Check the type(s) of work you would be willing to accept:
Regular full-time
Regular part-time
Temporary full-time
Temporary part-time
Substitute 		Check the area(s) where you would accept work:
Carrboro
Chapel Hill
Durham
Hillsborough
Pittsboro
Roxboro
Siler City
Enter the date you could begin work (month/day/year):
POSITIONS SEEKING
Enter below the specific title(s) of the job(s) for which you are applying. For a listing of our current vacancies, please visit our Employment Opportunities page. Please list no more than three positions on this application.
EDUCATION
Choose the highest education level completed:
Schools Name and Location Graduated? Type of Degree Major
High School Yes
Colleges/Universities Yes
Graduate/Professional Yes
Vocational/Other Yes
SKILLS, LICENSES AND CERTIFICATIONS
Skills which you have - check as many as apply:
Adding machine/calculator
Typing
Word processing
Data entry
Computer skills (specify at right)		 If you have computer skills, specify programs:
What languages other than English do you speak?

 Please list any professional licenses/certifications you currently have:
Have you ever been convicted of an offense against the law other than a minor traffic violation? (A conviction does not mean you cannot be hired. The offense and how recently you were convicted will be evaluated in relation to the position for which you are applying.) Yes


If yes, explain fully:
WORK HISTORY | Begin with present and work backwards
Current or Last Employer:
 Address:
Job Title:
 Supervisor's Name and Title:
Supervisor's Phone Number:



Employed for years/months If part-time, number of hours per week:
Date Employed: Date Separated:
Starting Salary: Reason Separated:
May we contact employer?


Ending or Current Salary:
List major duties and population served while on this job:
Employer:
 Address:
Job Title:
 Supervisor's Name and Title:
Supervisor's Phone Number:



Employed for years/months If part-time, number of hours per week:
Date Employed: Date Separated:
Starting Salary: Reason Separated:
May we contact employer?


Ending Salary:
List major duties and population served while on this job:
Employer:
 Address:
Job Title:
 Supervisor's Name and Title:
Supervisor's Phone Number:



Employed for years/months If part-time, number of hours per week:
Date Employed: Date Separated:
Starting Salary: Reason Separated:
May we contact employer?


Ending Salary:
List major duties and population served while on this job:

If you would like to submit your resume along with this application, please copy and paste it into the space below. Please note that formatting other than paragraphs will be lost.
Pre-Employment Inquiry Release

This section of the application will be used only if you are offered a position with OPC.

In connection with my application for employment with OPC Area Program, I understand that investigative inquiries are to be made on myself including criminal, driving, education, and social security trace reports. These reports will include information as to my character, work habits, performance and experience, along with reasons for termination of past employment from previous employers. I understand that OPC will be requresting information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, criminal and other experiences.

I authorize, without reservation, any party or agency conctacted by OPC Area Program to furnish the above mentioned information.

Some information may have already been provided earlier in this application; please be sure it is filled out fully here as well.

Last Name First Name Middle Name
Maiden Name Social Security Number Date of Birth (xx/xx/xxxx)
Current Address City State:
Zip Code County How long living here?
Home Phone: Driver's License Number:
  
If moved to North Carolina within the past year:
Previous Driver's License Number:
 Previous County of Residence:

 Previous State of Residence:
Name/City/State of Educational Institution from which you received your highest degree:
 Type of Degree/Major:
Applicant Flow Data Sheet

OPC's policy prohibits discrimination based on race, sex, color, creed, national origin, age, sexual orientation, disability, or political or religious opinions or affiliations. The information requested below will in no way affect you as an aplicant. Its sole use will be to determine how our recruitment efforts are reaching all segments of the population.
Date of Birth (Month/Day/Year): Disability*
None/Prefer not to report
Blind or severely visually impaired
Deaf or severely hearing impaired
Loss or limited use of arms and/or hands
Non-ambulatory (must use wheelchair)
Other orthopedic impairment (including amputation, arthritis, back injury, cerebral palsy, spina bifida, etc.)
Respiratory impairment
Nervous system/Neurological disorder
Mental retardation
Learning disability
Others (heart disease, diabetes, speech impairment - please specify below
Sex:




Ethnicity:
American Indian/Alaskan Native
Asian/Pacific Islander
Black, African-American
Hispanic
White
Other (Please specify below)
Referral Source: Please indicate how you found out about the vacancy.




NEWSPAPERS:







WEB SITES:



(Specify below)

 Vietnam Veteran

*"Disability means, with respect to an individual: (1) a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (2) a record of such impairment; or (3) being regarded as having such an impairment." (Americans with Disabilities Act of 1990).

The reporting of a disability is strictly voluntary. Persons with disabilities who do not wish to report their disabilities should check "None/Prefer not to report". Information reported on this form will be kept confidential as required by state law. Public disclosure of this information without your consent would be a violation of GS 126-27.
Drug and Alcohol Consent Release Form

I understand that under certain circumstances outlined in OPC Area Program's Drug and Alcohol Testing Policy, drug and alcohol testing is a condition of my employment, or, if currently employed by OPC Area Program, my continued employment. I consent to the collection of blood, urine, hair, or other specimens for the purpose of drug and/or alcohol testing, the analysis of the collected samples, the disclosure of the test results to the company or the designees, and the use of such results for purposes related to my application for employment or continued employment with OPC Area Program. I release OPC Area Program, the collection agency, the testing laboratory and their employees and agents from all claims associated with the collection and analysis of the specimens and the use or disclosure of the test results and other information related to the testing.

I understand that nothing in this document constitutes a guarantee or offer of employment, or alter in any way the nature of my employment relationship with OPC Area Program.

WARNING! PLEASE READ CAREFULLY. THIS FORM CONTAINS CONSENT TO DRUG/ALCOHOL TESTING AND A RELEASE OF CLAIMS.

THE UNDERSIGNED FURTHER STATES THAT HE OR SHE HAS READ THE DRUG AND ALCOHOL CONSENT & RELEASE FORM AND KNOWS THE CONTENTS THEREOF AND SIGNS THE SAME OF HIS OR HER OWN FREE WILL.

INITIAL NOTICE TO EMPLOYEES OR CANDIDATES FOR EMPLOYMENT:

In accordance with 13 NCAC 20.0401, the notice below explains your rights and responsibilities under the North Carolina Controlled Substances Examination Regulation Act (CSERA).

•  You may refuse this test; however, your job or employment opportunity may be in jeopardy.

•  Candidates may be screened for controlled substance by means of a “quick test;” any positive results must be screened and must be confirmed by an approved lab using gas chromatography with mass spectrometry (GC/MS) or equivalent scientifically accepted method before hiring decisions are made.

•  Current employees cannot be screened for controlled substances by means of a “quick test.”

•  An approved laboratory must perform controlled substance testing of samples.

•  You can request a retest of any sample positive for controlled substances. Re-tests must be of the same sample and must be paid for by the employee.

•  You can file a complaint with the N.C. Department of Labor, (919) 807-2796 or 1-800- LABOR-NC, if you believe procedural requirements of the CSERA were violated. The Department has no jurisdiction regarding OPC Area Program's requirement for controlled substance testing or its decisions regarding results of controlled substance testing.

  

I certify that I have given true, accurate and complete information on this form to the best of my knowledge. In the event confirmation is needed with my work, I authorize educational institutions, associations, registration and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigation of all statements made in connection with this application and understand that false information or documentation or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and (or) criminal action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications. (Authority G.S. 126-30 G.S. 14-122 1) I understand that as a condition of employment I will be required to undergo drug and alcohol testing.