HOUSING AUTHORITY OF THE CITY OF ASHEVILLE
EMPLOYMENT APPLICATION

An Equal Opportunity Employer — Reasonable Accommodation Upon Request to ADA Coordinator

INSTRUCTION: Read the Job Announcement for complete job information and requirements before filling out this application.
All applicants must submit a complete (including hours worked per week), current, separate and signed application for each position
applied for. The Housing Authority will not review or research previous applications, employment history, or personnel records to
obtain information. Do not submit a resume or any other type of application for this official Housing Authority Employment
Application. Please type or print clearly using ink. Label any attachments with your full name and Social Security Number.

Application for Position of: Date Received by Authority
(Use title from Job Announcement)

Name Social Security Number

I /

Last First Middle Phone Numbers

Address Home: ( , )

Work: ( )

Number Street Apartment #
Are you 18 or older? " Yes

City/County State Zip Code n No

Are you currently employed? q Yes 6b Have you ever worked for q Yes If yes, date leftthe Housing Authority? I
q No q No I Mo Day Year

Highest grade completed lb Do you have a high school diploma? q 'Yes q No
If not, do you have a high school
equivalent diploma? q Yes q No

Name and location (city & state)
of college(s) or university(ies) Dates Attended

Total Credit
Hours Degree Received?

attended Major Field of StudyFrom To Sem Qtr Yes No 4 Yr. 5 W. Type

Other training (including business, trade, military, or correspondence schools) Total

Name and location of school (city & state) Type of training Hrs Wks

0 Use this space to give any special qualifications relevant to the position for which you are applying which are not covered elsewhere
in your application (such as professional license or certificate, skills in operation of machines/equipment, technical skills, or other special
training).

EXPERIENCE

INSTRUCTIONS: Use the following blocks A through E to provide information about your previous jobs
starting with your present or most recent position in block A. Include all relevant paid, non-paid, volunteer
and military experience. List promotions as separate jobs. You must complete all questions on this Housing
Authority Employment Application form. If more space is needed, attach additional pages with the same
information as required in blocks A through E. Label all attachments with name and Social Security Number.
Questions for which additional information is being given must be clearly referenced.

Position Name, title, and phone number of immediate supervisor

Employer (company or organization) Address of employer

Dates of Employment Describe your dut es, responsibilities, and accomplishments below.
(Information must be completed)

From To

Mo Day Year Mo Day Year

Last Salary per

Number of hours worked per
week, if different from 40 hours:

Number of employees you supervised

Reason for leaving:

Position Name, title, and phone number of immediate supervisor

Employer (company or organization) Address of employer

Dates of Employment Describe your dules, responsibilities, and accomplishments below.
(Information must be completed)

From To

I I I /
Mo Day Year Mo Day Year

Last Salary per

Number of hours worked per
week, if different from 40 hours:

Number of employees you supervised

Reason for leaving:

Position Name, title, and phone number of immediate supervisor

Employer (company or organization) Address of employer

Dates of Employment Describe your duties, responsibilities, and accomplishments below.
(Information must be completed)

From To

/ I I
Mo Day Year Mo Day Year

Last Salary per

Number of hours worked per
week, if different from 40 hours:

Number of employees you supervised

Reason for leaving:

Position Name, title, and phone number of immediate supervisor

Employer (company or organization) Address of employer

Dates of Employment Describe your duties, responsibilities, and accomplishments below.
(Information must be completed)

From To

I
Mo Day Year Mo Day Year

Last Salary per

Number of hours worked per
week, if different from 40 hours:

Number of employees you supervised

Reason for leaving:

Position Name, title, and phone number of immediate supervisor

Employer (company or org anization) Address of employer

Dates of Employment Describe your duties, responsibilities, and accomplishments below.
(Information must be completed)

From To I
Mo Day Year Mo Day Year

Last Salary per

Number of hours worked per
week, it different from 40 hours:

Number of employees you supervised

Reason for leaving:

Do you have a valid Driver's License? (Answer only if required for the position)
q Yes q No

May we ask your present employer about you?
C:1 Yes 0 No

Have you ever been convicted of a criminal offense including DWI or DUI in any court?
If yes, give date, place, charge, court and fine or sentence of conviction. 0 Yes I 0 No

A conviction does not automatically mean that you cannot be hired. The nature of the offense and when it
occurred will be considered. Give all of the facts so that a decision can be made (attach additional sheets,
if necessary).

A firing or forced resignation does not automatically mean that you cannot be hired. The circumstances, time
elapsed, and recent employment record will be considered (attach additional sheets, if necessary).

Are you willing to work:
(check all that apply) q Part-time 'full-time q Temporary q Permanent

(less than 40 hours) (40 hours)

:;771 Please describe any additional experience (paid or volunteer), activities or accomplishments that are relevant to the position for which
you are applying. Include name of organization, dates, and amount of time involved. (Do not use this block to list work experience

as required in blocks A through E).

This application is true and complete to the best of my knowledge. I understand that any false or incomplete answer may be grounds for not hiring
me or for dismissing me after I begin work, and that I may be required to verify all information I have given on this application. I further understand
that my employment is at-will, and that my employment and compensation can be terminated, without cause or advance notice, at the option of
either the Housing Authority or myself.

I understand that I will be required to pass a drug screening test and a post-offer physical examination, and to produce documentation verifying
identity and employment eligibility in the U.S., as conditions of my employment. I further understand that I may be required to provide a copy of
my driving record if driving is an essential component of the job for which I am applying. I acknowledge that this complete application is the property
of the Housing Authority of the City of Asheville and will not be returned, and that it is my responsibility to notify the Personnel Department of any
change in my name, address, phone number or any other pertinent information.

I understand that consideration for employment is contingent on the results of a reference and background check. Therefore, I hereby authorize
the Housing Authority to: 1) investigate the truthfulness of all statements made on this application; 2) contact my former employers and other listed
references or any other persons who can verify information; and 3) discuss the results of any investigation with other employees of the Housing
Authority involved in the hiring process. In addition, I give my consent for all contacted persons including former employers to provide information
concerning this application, and I release each such person from liability for providing information to the Housing Authority."

Signature of Applicant: Date:
(NOTE: UNSIGNED APPLICATIONS MAY BE REJECTED WITHOUT FURTHER NOTICE)

verified
person

Disclosure, Authorization & Consent to Obtain Consumer Report

The information included in this notice is NOT intended to be, nor should it be construed
as, legal advice concerning your obligations under the Fair Credit Reporting Act or any
other federal, state, or local laws and regulations. The below should be adapted to fit the
specific needs of your organization. If you have any questions regarding your legal rights
or responsibilities, please seek qualified legal counsel.

The Fair Credit Reporting Act requires employers to seek applicant/employees
authorization with regard to the procurement of a consumer and/or investigative
consumer report. Please note that CA, MN and OK state laws require a check box for
an applicant to request copies of report.

Dear Employee,

As required by the Fair Credit Reporting Act, this is to advise you that, in connection with your
application for employment, contract or volunteer services, Housing Authority of the City of
Asheville (HACA) may obtain information about you from a consumer reporting agency.
Information requested may regard your character, general reputation, personal characteristics, or
mode of living.

HACA reserves the right to obtain a consumer report at any time during the application process.
If hired, HACA also reserves the right to obtain a consumer report at any time during your
ongoing employment with us.

Prior to taking an adverse action based, in whole or part, on the information contained in your
consumer report, HACA will provide you with a Notification of Pre-Adverse Action that will
accompany a copy of your report and a summary of your rights under the Fair Credit Reporting
Act.

I acknowledge receipt of the above notice and I authorize HACA to obtain a consumer report.

Print Name:

Signature:

Date:

Date of Birth:

Social Security Number:

Transit Driver's Disclosure Form

Effective September 13, 1997, all motor vehicle records are subject to the Federal
Driver's Privacy Protection Act (FDPPA) and General Statute (GS) 20-43.1. The
EDPPA and GS 20-43. I require that information in the Division of Motor Vehicle
Records (MVR) be closed to the public. Personal information from these records
may be released to individuals or organizations that qualify under one of the
fourteen exceptions listed on the back of this form. These exceptions are
summarized of permissible uses.

Name of Driver:

DL#: State of DL#: Phone#:

Address of Driver:

By signing this form, you are granting the company access to your personal
information under exception number 13 of the FDPPA and GS 20-43.1.

Name of Company:

Signature of Driver:

Today's Date:

My signature on this document acknowledges that I understand that improper
release of information and/or false representation to gain information from DMV's
records is prohibited and is subjected to civil action.

Name of Company:

Name of Contact/requester:

Date: Phone#:

Signature of Contact Person: