EMPLOYMENT APPLICATION

(WE ARE AN EQUAL OPPORTUNITY EMPLOYER)




THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE AN EMPLOYMENT CONTRACT BETWEEN THE EMPLOYEE AND THE AGENCY. THIS DOCUMENT
DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS. THE AGENCY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT,
IN WHOLE OR IN PART. NO PROMISES OR ASSURANCES, WHETHER WRITTEN OR ORAL, WHICH ARE CONTRARY TO OR INCONSISTENT WITH THE TERMS
OF THIS PARAGRAPH CREATE ANY CONTRACT OF EMPLOYMENT.



WE CONSIDER APPLICANTS FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, CREED, GENDER, NATIONAL ORIGIN, AGE, DISABILITY,
MARITAL OR VETERAN STATUS, SEXUAL ORIENTATION OR ANY OTHER LEGAL PROTECTED STATUS.


ACCORDING TO THE SOUTH CAROLINA CODE OF LAWS, CHILDREN’S CODE CHAPTER 7, SECTION 20-7-2725, (ATTACHED) A PERSON WHO HAS BEEN CONVICTED OF A CRIME
ENUMERATED IN SUBSECTION (A) WHO APPLIES FOR EMPLOYMENT WITH, IS EMPLOYED BY, OR SEEKS TO PROVIDE CAREGIVER SERVICES OR IS A CAREGIVER AT A HEAD
START CENTER IS GUILTY OF A MISDEMEANOR AND, UPON CONVICTION, MUST BE FINED NOT MORE THAN FIVE THOUSAND DOLLARS OR IMPRISONED NOT MORE THAN ONE
YEAR, OR BOTH.

APPLYING FOR:

HOW DO WE CONTACT YOU?


TELL US ABOUT YOUR EDUCATION: (College information is only required if it is a job position requirement.)


YesNo


YesNo

GIVE NAME AND ADDRESS OF SCHOOL, MAJOR COURSE OF STUDY AND DEGREE RECEIVED.




YesNo

If yes provide:


YesNo

DO YOU HAVE ANY RELATIVE(S) EMPLOYED WITH WACCCAMAW EOC, INC.? IF YES, PLEASE PROVIDE NAME(S) BELOW:


YesNo


Note: Omit minor vehicle violations and any offense committed before your 17th birthday, which was adjudicated in juvenile court or under a
youthful offender law. Conviction of a criminal offense is not a bar to employment in all cases. Each conviction is evaluated individually.


YesNo


YesNo


YesNo

Reference 1.

(Name)

Reference 2.


ARE YOU RELATED TO ANY PERSON WHO CURRENTLY SERVES ON THE WACCAMAW EOC, INC. BOARD OF DIRECTORS? (List attached) IF YES, PLEASE PROVIDE
NAME(S) BELOW:

TELL US ABOUT YOUR WORK EXPERIENCE:

Describe your work experience in detail, beginning with your current or most recent job. Include military service (indicate rank) and job related volunteer
work, if applicable. If you have gaps in service, attach a separate sheet with explanation of gaps. All information in this section must be complete. A resume may be attached, but not substituted for completing this section.


YesNo


YesNo


YesNo

SECTION 20-7-2725. Childcare center employment.

(A) No childcare center, group childcare home, family childcare home, or church or religious childcare center may employ a person or engage the services of
a caregiver who is required to register under the sex offender registry act pursuant to Section 23-3-430 or who has been convicted of:

(1) A crime listed in Chapter 3 of Title 16, Offenses against the Person;

(2) A crime listed in Chapter 15 of Title 16, Offenses Against Morality and Decency;

(3) The crime of contributing to the delinquency of a minor, contained in Section 16-17-490;

(4) The felonies classified in Section 16-1-10(A), except that this prohibition does not apply to Section 56-5-2930, the Class F felony of driving under
the influence pursuant to Section 56-5-2940(4) if the conviction occurred at least ten years prior to the application for employment and the following
conditions are met:

(a) The person has not been convicted in this State or any other state of an alcohol or drug violation during the previous ten-year period;

(b) The person has not been convicted of and has no charges pending in this State or any other state for a violation of driving while his license is
canceled, suspended, or revoked during the previous ten-year period; and

(c) The person has completed successfully an alcohol or drug assessment and treatment program provided by the South Carolina Department of Alcohol and
Other Drug Abuse Services or an equivalent program designated by that agency.

A person who has been convicted of a first-offense violation of Section 56-5-2930 must not drive a motor vehicle or provide transportation while in the
official course of his duties an employee of a childcare center, group childcare home, family childcare home, or church or religious childcare center.

If the person subsequently is convicted of, receives a sentence upon a plea of guilty or of nolo contendere, or forfeits bail posted for a violation of
Section 56-5-2930 or for a violation of another law or ordinance of this State or any other state or of a municipality of this State or any other state
that prohibits a person from operating a motor vehicle while under the influence of intoxicating liquor, drugs, or narcotics, the person’s employment must
be terminated;

(5) The offenses enumerated in Section 16-1-10(D); or

(6) A criminal offense similar in nature to the crimes listed in this subsection committed in other jurisdictions or under federal law.

Certification of Applicant:
By my signature, I affirm, agree, and understand that all statements on this form are true and accurate. Any misrepresentation, falsification, or material
omission of information or data on this application may result in exclusion from further consideration or, if hired, termination of employment. If I have
requested herein that my present employer not be contacted, an offer of employment may be conditioned upon acceptable information and verification from
such employer prior to beginning work.

Signature

Today’s Date

2015 Board of Directors

Horry County

Tewana Alston

Harold Phillips, Board Chair

Roderick Smith

Georgetown County

Brenda Perkins

Louis Morant

Caitlin Newquist

Sarah Keith

Williamsburg County

Theresa Brooks

Jeanie Brown-Burrows

Alfred Jean-Pierre, Jr.

Michael Scott




AUTHORITY TO RELEASE INFORMATION

RELEASE AND DISCLOSURE FORM

By my signature, I consent to the release of information to authorized officers, agents, and/or employees of Waccamaw EOC, Inc. which may include but not be limited to:

  • Information concerning your present and past work. If you elected for your present employer to not be notified for a reference, they will be notified
    after an employment opportunity has been offered. The information requested may be official personnel files, attendance records, evaluations,
    educational records including transcripts, and military service.
  • Alcohol and/or drug assessment testing.
  • Fingerprint review by the State Law Enforcement Division (SLED) to determine any state criminal history and a fingerprint review conducted by the
    Federal Bureau of Investigation (FBI) to determine any other criminal history.
  • Ten year driving record history from the South Carolina Department of Highways.
  • Staff Health Assessment to include a Tuberculosis certification, completed by physician to determine fitness for work and to check for communicable
    diseases which would prohibit a person from working in a child care facility. Persons are also at risk of exposure to childhood diseases by working in
    a child care facility.
  • A Search of the Central Registry of Child Abuse and Neglect.
  • A Homeland Social Security Check.
  • Credit report furnished by a Consumer reporting Agency such as Experian, Trans Union, or Equifax.

You will be notified if an adverse action is taken on the basis of any of the above reports. The company will be identified that provided the report, so
you will have the opportunity to verify or contest the report. (See attachment, Appendix A to Part 601 of the Summary of Rights published by the Federal
Trade Commission).

This authorization will be in effect until the undersigned person revokes the authorization in writing to this Agency.