Employment Application Editable PDF - 2

Name: _______________________________________________

(Please Print)

Date:________________

EMPLOYMENT APPLICATION

DCCC Employment Application 02/2011

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EMPLOYMENT APPLICATION

Delaware County Community College is an equal employment and educational opportunity institution conforming to all applicable legislation that prohibits discrimination. The College does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation or any other characteristic protected by state or federal laws in its educational programs, activities, admission or employment policies as required by Title IX of the Educational Amendments of 1972, Section 504 of the rehabilitation Act of 1973 and other applicable and other applicable statutes. Inquiries concerning Title IX and/or 504 compliance should be referred to: Associate Dean for Student Success, room 2195, 610-359-5320; and/or Vice President of Human Resources, room 3572, 610-359-5094. TTY for the hearing impaired: 610-359-5020.

1. PERSONAL

Last Name

First

Middle

Street Address

City

Township/County

State

Zip Code

Home Telephone Email address: Title of Position you are applying for:

Work Telephone

Full Time

Part Time

How did you hear of this position? (Specify Source: Employee Referral, Advertising, Web Site Etc.)

If you are related to any current employee of the College, please indicate the name and relationship:

When will you be available to begin work?

Have you ever been convicted of a felony?

Yes

No If yes, provide details:

Are you legally eligible to work in the United States?

Yes

No

Proof of eligibility is required upon hiring

Note: In case of conviction, a review will be conducted evaluating the amount of time since the conviction, employment history, the relationship between the type of employment and the crime involved. This application will not be considered if this question is not answered.

DCCC Employment Application 02/2011

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2. EDUCATION

In the space below, please enter schools you have attended, dates attended, degrees received and your primary area of study.

School

Graduate/ Professional

Name/ Location

Course of Study Graduated? Year of Graduation

Yes

Degree/ Diploma

No

Graduate/

Professional

Yes

No

College/

University

Yes

No

College/

University

Yes

No

Business/Trade/

Technical

Yes

No

High School/

GED

Yes

No

3. REFERENCES

Please list the name, telephone number, and relationship of 3 individuals (not related to you) who are familiar with your qualifications for this position.

Name

Telephone

Relationship

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4. EMPLOYMENT HISTORY

List all present and past employers, starting with the most recent. In Title/Resp. block, describe the nature of the work performed by you.

Dates of Employment (From ?To)

Employer Name and Address, Phone

Supervisor Name & Title

Rate of Pay

Your Title & Responsibilities

Reason for Leaving

Dates of Employment (From ?To)

Employer Name and Address, Phone

Rate of Pay

Your Title & Responsibilities

Supervisor Name & Title Reason for Leaving

Dates of Employment (From ?To)

Employer Name and Address, Phone

Rate of Pay

Your Title & Responsibilities

Dates of Employment (From ?To)

Employer Name and Address, Phone

Rate of Pay

Your Title & Responsibilities

DCCC Employment Application 02/2011

Supervisor Name & Title Reason for Leaving

Supervisor Name & Title Reason for Leaving

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Acknowledging Statement

(Application must be signed below prior to submission)

I understand that nothing in this application is intended to imply or create an employment relationship or contract for employment.

I certify that, to the best of my knowledge, all information set forth in my application, resume, and associated documents and forms (including but not limited to transcripts) is true and complete. I authorize Delaware County Community College to investigate and verify any statements made or information contained in these documents. I understand that, any falsifications, misrepresentations or omissions of fact may be grounds for rejection of my application or discharge from subsequent employment and that it will make null and void any pre-employment commitments made by Delaware County Community College.

I understand that consideration for employment in this position is contingent upon the results of a background check and references. I therefore authorize Delaware County Community College and its agents, officers, and employees to conduct an investigation of my background and references as may be considered necessary in relation to the position of

____________________________________________.

I authorize Delaware County Community College to verify all information which I have provided. I consent to and authorize all persons and organizations that may have information concerning me to disclose such information to the College or its authorized agents. I hereby release the College, its authorized agents, and all persons and organizations providing information from all claims and liabilities of any nature in connection with this release of information. I hereby further authorize that a photocopy or telephonic facsimile or electronic transmittal of this authorization may be considered as valid as the original. I understand that my signature does not guarantee employment with Delaware County Community College.

If I am employed, I agree to conform to the College's rules and regulations. In the event of employment, I understand that false, incomplete or misleading information in my application, interview or submissions provided to the College could result in termination of employment.

I have read and agree to the above statements and I affirm that a photocopy of this information is to be considered valid. Name (print) __________________________________________________________________

Signature: _______________________________________________

Date: _____________________________

By checking the above box I affirm that the information on application is

accurate to the best of my knowledge. An application remains active only for the duration of the current search.

Applicants may attach a copy of their resume and/or CV along with other pertinent documents and submit to:

Delaware County Community College Human Resources

901 South Media Line Road Media PA 19063

Or Via email to hr@dccc.edu

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