Position applying for:

A) PERSONAL INFORMATION

Full Name
Address
City
State Zip
Home Phone
Mobile/Pager/Other
E-mail
E-mail (Re-enter email address)

B) EDUCATION

Name of School
City/State
Dates of Attendance
Major
Minor
Degree

Name of School
City/State
Dates of Attendance
Major
Minor
Degree

Name of School
City/State
Dates of Attendance
Major
Minor
Degree

Name of School
City/State
Dates of Attendance
Major
Minor
Degree


C) PROFESSIONAL WORK EXPERIENCE

List most recent position first. Fill out completely; do not indicate “refer to resume.” All professional work experience must be listed; if necessary attach additional information.


Company Name
Address
City
State Zip
Phone

Supervisor
Title + Phone

Dates of Employment: From To
Position(s) Held


Beginning Salary
Current Salary
Your Position or Title
Full Time or Part Time

Nature Of Duties



Reason for leaving


May we contact this employer for a reference? Yes No

Company Name
Address
City
State Zip
Phone

Supervisor
Title + Phone

Dates of Employment: From To
Position(s) Held


Beginning Salary
Current Salary
Your Position or Title
Full Time or Part Time

Nature Of Duties



Reason for leaving


May we contact this employer for a reference? Yes No

Are you legally allowed to work in the United States? Yes No


Have you been convicted of a serious crime within the last five years which is substantially related to the responsibilities of the position for which you are making application or of past positions held?
Yes No
If yes, Explain:



Have you ever been disciplined or discharged for theft of company or public property or related offenses? Yes No

If yes, Explain:



Have you ever been disciplined or discharged for fighting, assault or related offenses?
Yes No
If yes, Explain:


Have you ever been disciplined or discharged for insubordination? Yes No
If yes, Explain: :



Have you ever been disciplined or discharged for violating a safety rule(s)?
Yes No
If yes, Explain:


Have you ever been disciplined or discharged for sexual harassment?
Yes No
If yes, Explain:



D) Narrative Statements


Discuss briefly those unique qualifications that you possess which would enhance your position as a potential professional employee at Carbon County Higher Education Center.


Discuss what you have done in your most recent positions to implement positive changes which would relate to your field of instruction and/or professional position for which you are applying.


State briefly your views on the role of a community college in relation to the public, faculty, and students it serves.



E) Professional References
List those individuals, except former supervisors, who are familiar with your work and/or professional credentials.

Please list 4 references in the boxes below as follows: Name, Telephone, Organization, and City and State.

Reference #1


Reference #2


Reference #3


Reference #4



F) Certification

I hereby certify that, to the best of my knowledge and belief, the answers to the foregoing questions and statements made by me are complete and true. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize any present employer or supervisor, past employer or supervisor, college, university or other institution of learning, law enforcement agency, state agency, federal agency, private business, military branch or the National Personnel Records Center, personal references, and for other persons to give records or information they may have concerning my employment, worker’s compensation claims, criminal history, motor vehicle history, earnings history, health, character and employment records or any other information requested to CARBON COUNTY HIGHER EDUCATION CENTER. I voluntarily and knowingly unconditionally release any named or unnamed informant from any and all liability resulting from the furnishing of this information.

Signature (please type your full name)
Date

Carbon County Higher Education Center does not discriminate on the basis of race, color, national origin, gender, age, disability, political affiliation, religion, or belief in relation to admission, treatment of students, access to programs and activities, or terms and conditions of employment.