EQUAL OPPORTUNITY EMPLOYER QUESTIONNAIRE
In order to comply with United State Government Equal Opportunity requirements, all applicants for
employment are requested to complete this form. This form is not part of the application packet.
Data collected will be used for statistical reporting purposes and to measure the effectiveness of
recruitment efforts and selection procedures. This information is requested on a voluntary basis, will
be kept confidential, and is not available to hiring authorities.
North State Environmental, Inc. is an equal opportunity employer. In accordance with applicable
laws and regulations, North State Environmental, Inc. does not discriminate on the basis of disability
or other prohibited criteria. If you believe you have been treated unfairly or discriminated against on
the basis of race, color, national origin, gender, age, religion, political affiliation, sexual orientation, or
disability, please contact the Human Resources Manager at (336) 725-2010, ext. 1020
Thank you for completing an application for this position and in your decision to select North State
Environmental, Inc. as a possible employer. If you need clarification of information on this form
please contact the Human Resources Manager at (336) 725-2010, ext. 1020.
(Refusal to complete this form will have no effect whatsoever on consideration for employment.)
Person with a disability: Any person who has a physical or mental impairment that substantially limits one or more major life activities and that affects employability, has a record of having such impairment, or is regarded as having such impairment.
North State Environmental Drug and Alcohol Use Policy
North State Environmental, Inc. strives to provide a drug-free, healthful, and safe workplace. All
employees are expected to report to work in a mental and physical condition which enables you to
perform your job in a satisfactory manner.
While on North State Environmental, Inc.'s premises or while conducting business-related activities
off North State Environmental, Inc.'s premises, you may not use, possess, distribute, sell, or be under
the influence of alcohol or illegal drugs. We permit the legal use of prescribed drugs on the job only
to the extent they do not impair your ability to perform the essential functions of your job effectively and safely without endangering others.
If you are prescribed a drug that may affect your ability to perform your job, you must notify your
supervisor and provide a medical document to explain the effects of the drug, prior to returning to
Violation of this policy will lead to disciplinary action, up to and including immediate termination of
your employment as well as possible legal repercussions. Additionally, you may be required to
participate in a substance abuse rehabilitation or treatment program.
If you have questions about this policy or issues related to drug or alcohol use at work, you can raise
your concerns with your supervisor or the Owner without fear of reprisal.
AUTHORIZATION FOR RELEASE OF INFORMATION AND WAIVER OF LIABILITY FOR EMPLOYMENT REFERENCES
to provide information to my prospective employer pertaining to my employment.
I hereby voluntarily waive any and all rights I may have to privacy and/or confidentiality pertaining to my employment history and work performance insofar as the information is released solely to employers who are evaluating my suitability for employment.
This authorization shall remain valid for 90 days from the date of signature.
from any claims, damages or liabilities of any kind, that may directly or indirectly result from the use, disclosure, or release of such information by any person or party, whether such information is favorable or unfavorable to me, arising from the employment reference as contemplated by this authorization.
I have read the above, understand its contents, and voluntarily agree to its terms.