unc application

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					For Office Use Only

Part-time Full-time

Accounting Light Ind.

Clerical Soc. Research

Computer Lab Research

Library

E

G

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Application for Temporary Employment
University PID#

Last Name

First Name

Middle/Maiden Name

Preferred Name

Address

Home Phone

City

State

Zip

Alternate Phone

Emergency Contact

Relationship to You

Contact Person’s Phone No.

Tar Heel Temps
Type of Work Preferred: Date Available To Work:

Cell Phone

Email

AVAILABILITY INFORMATION

SEEKING PERMANENT EMPLOYMENT

_____ Yes

_____ No

Minimum Hourly Wage Acceptable:

Available Until:

Number of Hours per Week:

Preferred Schedule:

Hours Available:

MON

TUE

WED

THU

FRI

SAT

SUN

EDUCATION AND TRAINING
Highest Level Completed (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 or GED): School Name and Location Mo. Attended From Yr. Mo. To Yr. College (1, 2, 3, 4, or GRAD): Type of Degree, Diploma, or Certificate Received and Major Area of Study Date Received

Mo.

Yr.

Mo.

Yr.

Mo.

Yr.

Mo.

Yr.

Please list any specific courses or workshops applicable toward area of work:

Do you have any previous University of North Carolina at Chapel Hill work experience?

YES
Temporary

NO
Permanent

Have you previously applied with Tar Heel Temps?

YES
Interviewed By:

NO
Date:

For Office Use Only

Crim Check

Checked By:

App. Update _______________
Applications Also Available Online at http://hr.unc.edu/tht

App. Update _______________

“CELEBRATING OVER 15 YEARS OF SERVICE”

Page 2

Equal Opportunity/Affirmative Action Employer

ADDITIONAL INFORMATION

YES

NO

Have you EVER been convicted of ANY unlawful offense, including misdemeanors, felonies, or PJCs (Prayers for Judgment Continued)? You must include all such convictions on the attached 'Authorization for Criminal Conviction Check.' Criminal background checks are verified prior to interview appointments. By completing this Application, you are authorizing The University of North Carolina at Chapel Hill to conduct a criminal convictions check on you. Simply having a criminal conviction on your record does not prevent you from being employed by the University. However, the nature of some convictions may cause certain positions to be unavailable to you. If you are found to have willfully provided false or misleading information about your criminal convictions history, you may become ineligible to be hired by the University for at least two years.

YES YES

NO NO

Are you related by blood or marriage to, or do you reside with, any person now employed by UNC at Chapel Hill? If Yes, give the employee’s name, department, and your relationship: Have you previously worked for Tar Heel Temps? If Yes, give dates, and name used (if different):

YES YES

NO NO

Are you now employed, or have you ever been employed by, the State of North Carolina, UNC at Chapel Hill, or UNC Health Care Systems? If Yes, give the positions, dates, and name used (if different): Do you have a valid North Carolina driver’s license? (If placed in a position where driving is required, driver’s license will be verified.)

Class:

DL#:

Expiration: What are your career goals?

Why are you applying for temporary employment?

How did you hear about Tar Heel Temps?

What would be your ideal job with Tar Heel Temps?

EMPLOYMENT/REFERENCES RECORD – FILL OUT COMPLETELY. A resume may be included as a supplement, but cannot be substituted for the completion of the Employment/Reference Record on this application. YES NO
May we inquire of your present employer regarding your experience and qualifications if you are employed now?
Employer Name and Address For Office Use Only

Title of CURRENT or LAST POSITION Employed From: To: Full Time Mo. Mo. Yrs. Yr. Yr. Mos.

Supervisor Name, Title, Phone #

Mos. Part Time (less Yrs. than 40 hrs.) If Part Time, number of hours worked per week: Starting Salary Ending Salary

Principal Job Duties

Reason for leaving/changing

Form THT-123 (05/27/2008)

Tar Heel Temps, Campus Box 1045, 104 Airport Drive, Chapel Hill NC 27599-1045

Equal Opportunity/Affirmative Action Employer

Page 3

EMPLOYMENT/REFERENCES RECORD (continued)
Title of previous position Employed From: To: Full Time Mo. Mo. Yrs. Yr. Yr. Mos. Supervisor Name, Title, Phone # Employer Name and Address For Office Use Only

Mos. Part Time (less Yrs. than 40 hrs.) If Part Time, number of hours worked per week: Starting Salary Ending Salary

Principal Job Duties

Reason for leaving/changing

Title of previous position Employed From: To: Full Time Mo. Mo. Yrs. Yr. Yr. Mos.

Employer Name and Address

For Office Use Only

Supervisor Name, Title, Phone #

Part Time (less Yrs. Mos. than 40 hrs.) If Part Time, number of hours worked per week: Starting Salary Ending Salary

Principal Job Duties

Reason for leaving/changing

Title of previous position Employed From: To: Full Time Mo. Mo. Yrs. Yr. Yr. Mos.

Employer Name and Address

For Office Use Only

Supervisor Name, Title, Phone #

Part Time (less Yrs. Mos. than 40 hrs.) If Part Time, number of hours worked per week: Starting Salary Ending Salary

Principal Job Duties

Reason for leaving/changing

Phone: 919-962-2900

Form THT-123 (05/27/2008)

Page 4

Equal Opportunity/Affirmative Action Employer

SKILLS SUPPLEMENT CHECKLIST — please check all skills that apply to your experience. ACCOUNTING SKILLS Accounts Payable Accounts Receivable Auditor Collections Contracts and Grants Cost Accounting Financial/Budget Analysis Income Statement (P/L) Invoicing Payroll Tax TIM (Kronos) UNC Accounting System – Finan$eer UNC Check Request Processing UNC Financial Data Warehouse UNC FRS UNC InDEPTh WebTravel ADMINISTRATIVE Confidential Records Contracts Event Planning Grants Personnel Records Professional Travel Arrangements UNC CABS CLERICAL Collating Copying/Faxing Filing COMPUTER — Databases Blackboard Create New Database Crystal Reports Database Management FileMaker Pro Microsoft Access Microsoft Project Oracle SQL Other: COMPUTER — Functions Charts and Tables Desktop Publishing Macros Mail Merge COMPUTER — Graphics AutoCAD InDesign PageMaker PhotoShop
Form THT-123 (05/27/2008)

PowerPoint Publisher QuarkXPress COMPUTER — Internet Related Cold Fusion Dreamweaver Flash Frontpage HTML JavaScript PHP Web Page Development COMPUTER — Operating Systems Mac OS Microsoft Windows UNIX/Linux COMPUTER — Spreadsheet Create Macros Create Spreadsheet Microsoft Excel COMPUTER — Technical Support Mac OS Microsoft Windows UNIX/Linux Help Desk/Troubleshooting Network Administration Programming Languages: Project Management Systems Analysis COMPUTER — Word Processing Microsoft Word WordPerfect DATA PROCESSING 10-Key by Touch Alpha/Numeric Data Entry Numeric Data Entry HUMAN RESOURCES Benefits Career Banding Classification/Position Management E-Verify Employee Records Employee Relations/Counseling Employment/Recruiting Interviewing/Hiring Training & Development UNC HR Facilitator UNC HRIS System
Tar Heel Temps, Campus Box 1045, 104 Airport Drive, Chapel Hill NC 27599-1045

Equal Opportunity/Affirmative Action Employer

Page 5

LANGUAGES French German Myanmar (Burmese) Sign Language Spanish Other: LIBRARY SKILLS Acquisitions Cataloging Circulation Manuscripts Reference Reserve Serials Shelving/Shelf Reading MEDICAL — Dental Dental Assistant Dental Hygienist MEDICAL — Environment Cardiology Dermatology General Medicine Hematology/Oncology Neurology OB-GYN Pediatrics Surgery MEDICAL — Experience CNA ICD-9/CPT Coding Insurance/Billing Lab Animal Tech LPN/RN Medical Lab Tech Medical Transcription Phlebotomy SMS-UNC Hospital Scheduling System WebCIS RECEPTION Executive Level Greet General Public Multi-Line Phone Receptionist Schedule Appointments Oracle Calendar Outlook Calendar

SECRETARIAL Executive General Correspondence Manuscript Proofreading/Editing Transcription/Dictaphone SERVICE INDUSTRY Audio Visual Equipment Bindery CDL (Commercial Driver License) Collator Operator Computerized Cash Register Construction/General Laborer Customer Service Delivery Driver Driver’s License Electrical Floor Tech Food Service/Snack Bar Grounds/Landscaping lbs. Heavy Lifting - Max HVAC Inventory Janitorial/Housekeeping Machine Maintenance / Repair Mailroom Oversized Vehicle for Work Use Exterior Painting: Interior Sales Shipping / Receiving Transporting Passengers SOCIAL RESEARCH Data Analysis Data Collection Human Subjects Training Report Writing Subject Interviewing/Observation UNC WORK EXPERIENCE UNC Healthcare UNC HRIS UNC Permanent Employee UNC Student/Grad Assistant UNC Temporary Employee

OTHER SKILLS NOT INCLUDED ABOVE: ____________________________________________________________________________________________________________

Phone: 919-962-2900

Form THT-123 (05/27/2008)

Page 6

Equal Opportunity/Affirmative Action Employer

CONDITIONS OF EMPLOYMENT
In order to be employed with the University of North Carolina at Chapel Hill as a Temporary Staff (SPA) Employee, you must agree to the following conditions of employment: 1. I understand that any offer of employment is conditional pending the completion of the University’s required criminal conviction check. I understand a criminal conviction in and of itself does not disqualify me from employment at the University. I understand that in the event a criminal conviction record is discovered where I had not listed it on the employment application, I may be disqualified from employment in this position, and any other position at the University, for falsification of the employment application. I also understand that due to the nature of some criminal convictions, employment in certain positions at the University may be unavailable to me. I understand that in the event that thirty (30) calendar days have elapsed since the initiation of my criminal convictions check with the University’s Department of Public Safety, I may be allowed to begin work at the University with the understanding that my employment offer may be rescinded if the criminal convictions check when received discloses information that affects my selection. I understand that before a final decision would be made to rescind my appointment, I would have the opportunity to provide any exculpatory or explanatory information. Federal law requires each new employee to complete the “Employee Information and Verification” section of the U.S. Citizenship and Immigration Services (Form I-9) and to submit certain original documents for examination in order to verify and certify identification and employment eligibility. In compliance with N.C. law, the University verifies each individual's legal status or authorization to work in the United States after hiring the individual using the Department of Homeland Security’s E-Verify Program. I understand that my employment will be terminated if I fail to comply with the employment authorization requirements or if it is determined that I am not authorized to work in the United States. State policy requires each Permanent Staff employee to be at least 18 years of age, and State law requires the University to have these individuals indicate their compliance with the Federal Military Selective Service Act. Initial the appropriate response below. ______ (initial) I certify that I am required to be and have registered with Selective Service, OR ______ (initial) I certify that I am exempt from registering with Selective Service, OR ______ (initial) I certify that I am required to be and have NOT registered with Selective Service. I understand that if I am not registered but am required to be, I MUST do so no later than 30 days from the appointment date indicated on this document in order to stay employed at the University. I understand that failure to comply with the registration requirement bars a person from State employment. I understand I am required to provide my Social Security Number so the University can satisfy its income-reporting and withholding obligations under North Carolina and federal laws. Unless this sentence is marked through and initialed by me, I voluntarily permit the use of my social security number for internal record keeping and information management operations. However, I understand I have been randomly assigned the personal identification number (PID) indicated on this document, which the University will use instead whenever possible. I understand that the University requires all presently-hired employees to be paid by direct deposit into a bank or credit union account, and that pay stubs will be provided to me electronically through the University’s E-pay program. In order to satisfy this requirement, I understand I must either present a deposit slip or voided check during my assigned Job Offer Acceptance Session or submit the direct payroll deposit authorization (Form PR-8) to the University Payroll Department by the end of my first work week. My signature below certifies I understand I will not receive a paycheck from the University until the appropriate payroll forms have been completed and submitted. I understand that the rules governing my work schedule, meal and break periods, time records, pay day, wage-hour status (for overtime purposes), and the policies covering equal employment opportunity, reporting an on-the-job injury, workplace violence, illegal drugs in the workplace, and other policies as listed on the “Certification of Review of Relevant Employment Policies” have been provided to me by a department representative. I authorize the University to withhold from my final paycheck the cost of any keys, uniforms, or other State-owned property I fail to return when my appointment ends. I also authorize the University to withhold from my final paycheck the amount of any other debt I owe to the University, subject to Wage-Hour requirements. I understand that if my position’s duties expose me to blood-borne pathogens or other potentially infectious material, I am required to attend the Environment, Health & Safety Office’s OSHA-required training within my first 10 days at work. I also understand that to comply with University policy, if my position's duties include engaging in University health care activities, I must: a. satisfactorily complete a tuberculosis screening skin test (PPD) within my first 10 days of work, and b. disclose to my department head, dean, division chief, Office of Human Resources Employee & Management Relations Division, or the chair of the University’s AIDS Task Force if I am currently, or later become, infected with either the HIV or Hepatitis B viruses. I understand that the University follows a “Smoke Free” policy and that smoking is not allowed within 100 feet of all University facilities, both on and off campus. I also understand that smoking in state-owned vehicles is also prohibited.

2.

3.

4.

5.

6.

7.

8.

9.

Employee’s Initials: (continued on next page)

Human Resources Rep Initials:

Form THT-123 (05/27/2008)

Tar Heel Temps, Campus Box 1045, 104 Airport Drive, Chapel Hill NC 27599-1045

Equal Opportunity/Affirmative Action Employer CONDITIONS OF EMPLOYMENT (continued)

Page 7

10. I understand that the only employee benefit programs in which I am eligible to participate are the voluntary 403(b) supplemental retirement and/or U.S. savings bonds programs. 11. I understand that my appointment is for a period of twelve calendar months or less, if retained, from the date of my first work day at the University of North Carolina at Chapel Hill (University) and that if I work for the University for 1500 hours or more within a 12-month period, my appointment must be terminated (effective no later than the last day of that 12-month period). I understand that I will not be eligible to be re-hired by the University in a temporary capacity for a minimum period of 31 days after the date my appointment was terminated. 12. (initials) For retirees only. I understand that State policy allows me, as a retiree, to work longer than twelve consecutive months regardless of the number of hours I work, and that my initials beside this condition certify that I am retired, am not available for (or seeking) permanent work, and have benefits (like health insurance) through my retirement plan.

13. I understand that in the event that I accept a permanent position with another North Carolina state agency or with another University department, I must inform my hiring department and terminate my temporary appointment.

Employee’s Signature / Date

Human Resources Representative Signature / Date

Phone: 919-962-2900

Form THT-123 (05/27/2008)

Page 8

Equal Opportunity/Affirmative Action Employer

ASSIGNMENT HISTORY (for office use only) WO# Start End Pay Position Dept Contact Person Phone

Form THT-123 (05/27/2008)

Tar Heel Temps, Campus Box 1045, 104 Airport Drive, Chapel Hill NC 27599-1045