Application for Employment An Equal Opportunity / Affirmative Action Employer
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1 Human Resource Office MS # Application for Employment An Equal Opportunity / Affirmative Action Employer 2011 Mottman Road SW Olympia, WA (360) FAX: (360) jobline@spscc.edu Instructions: To order to be considered for the position identified below, this application must be filled out completely, typed or printed in ink, and signed (electronic signatures accepted). Have you ever worked for South Puget Sound Community College? No Yes If yes, when? Position applying for: Full-time Part-time BOTH if applicable Personal Data Name Mailing Address City, State, Zip Code Recruitment Referral: Please tell us how you heard about this vacancy Newspaper please specify: Professional/Trade Journal please specify: Internet Source please specify: Job Announcement posted by Agency bulletin board please specify: Other source please specify: Walk-in Home Telephone Business Telephone Mobile Telephone Address List other names under which you have attended school, been employed, or known by: Veteran s Preference Eligibility for veteran s preference is defined in RCW as honorably discharged soldiers, sailors, and marines who are veterans of any war of the United States, or of any military campaign for which a campaign ribbon shall have been awarded, and their widows or widowers, shall be preferred for appointment and employment. Age, loss of limb, or other physical impairment, which does not in fact incapacitate, shall not be deemed to disqualify them, provided they possess the capacity necessary to discharge the duties of the position involved: PROVIDED, that spouses of honorably discharged veterans who have a service connected permanent and total disability shall also be preferred for appointment and employment. Are you a military veteran eligible for veteran s preference? No Yes Are you a widow/widower of a military veteran eligible for veteran s preference? No Yes Are you a spouse of an eligible military veteran with a service connected permanent and total disability? No Yes Applicants claiming veteran s preference eligibility may be required to provide documents to verify eligibility such as a DD 214 or NBR 22 Rev mw Page 1 of 5
2 Employment History 1 Employer Title 2 Employer Title 3 Employer Title 4 Employer Title 5 Employer Title Rev mw Page 2 of 5
3 Education Have you graduated from high school or received a GED certificate? No Yes Name of College or University City, State From: Mo/Yr To: Mo/Yr Degree or Diploma Earned Major Licenses and Certificates (List all of your professional licenses, permits, and certificates) Professional References Rev mw Page 3 of 5
4 Applicant s Certification and Agreement Please read carefully. I hereby certify that the information provided in this application is true and complete, and that there are no willful misrepresentations in and no falsification of any of the statements and answers to questions. I am aware that should investigation disclose any misrepresentations of falsifications; such disclosure will constitute grounds for rejection of application or immediate dismissal. I hereby consent to and authorize any of my former employers to furnish any and all relevant information concerning my previous employment record. I hereby consent to and authorize any of my previous educational institutions to furnish any and all relevant information concerning my previous educational record. I release all parties connected with any request for information from all claims, liability, and damages for whatever reason arising out of furnishing this information. If employed, I release South Puget Sound Community College from any liability for future references it may provide regarding my work history at South Puget Sound Community College. If I am employed, I understand that I must provide proof of employment authorization and of identity and will provide the documents when asked. I understand that I am responsible to South Puget Sound Community College for the replacement value of any College property that I retain beyond my exit date A photocopy of this release shall have the same effect as the original. I have read and understand the information on this application. Printed Name: Date: Signature: (not required for electronic submissions) South Puget Sound Community College (SPSCC) is an equal opportunity employer. We strive to create a working environment that includes and respects cultural, racial, ethnic, sexual orientations and gender identity diversity. Women, racial and ethnic minorities, persons with disabilities, persons over 40 years of age, disabled and Vietnam era veterans and people of all sexual orientations and gender identities are encouraged to apply. SPSCC complies with the Americans with Disabilities Act. Applicants needing accommodation in the application process in an alternative format may contact the Human Resources office at (360) SPSCC is committed to enhancing the diversity of our faculty and staff, as well as our student population. We strongly encourage applicants to apply without regard to race, color, religion, sex, sexual orientation, national origin, age, marital or veteran status, disability, or any other legal protected status. South Puget Sound Community College is a drug-free workplace. Rev mw Page 4 of 5
5 INFORMATION FOR FEDERAL AND STATE REPORTING PROGRESS. This supplemental information is for recordkeeping only As an Equal Opportunity Employer, South Puget Sound Community College is required to report the composition of its workforce to the state and federal government. The information on this form will be filed separately and will not be available to those processing your application. It will be available only to the person responsible for government reporting or for affirmative action reasons and safeguards will be used to prevent the discriminatory abuse of this information. Your voluntary cooperation will be appreciated. Position Name Social Security No. Birthdate Sex: Male Female Are you of Hispanic/Latino origin? (Check One) No, not Hispanic/Latino (999) Yes, Puerto Rican (727) Yes, Mexican, Mexican-Am., Chicano (722) Yes, Cuban (709) Yes, other Hispanic/Latino (Please Print) Which race do you consider yourself to be? (Choose one or more.) White (800) Black or African -American (870) Eskimo (935) Aleut (941) Hawaiian (653) Laotian (613) Chinese (605) Filipino (608) Japanese (611) Other Asian ( ) Korean (612) Vietnamese (619) Cambodian (604) American Indian (597) (Name of enrolled/principal tribe:) ( ) Pacific Islander (Please specify) ( ) Other Race (Please specify) ( ) Do you have a physical, sensory, or mental impairment which substantially limits one or more life activities (e.g., walking, seeing, hearing, breathing, or learning)? NO YES Do you have a physical, mental, or other health condition that has lasted for 6 or more months and which limits the kind or amount of work you can do at a job? NO YES VETERANS PREFERENCE * : Vietnam-Era Veteran: Served on active duty for more than 180 days, including any of the time period August 5, 1964 through May 7, 1975, and received other than dishonorable discharge, or released from active duty during the same period of time for service connected disability. Disabled Veteran: Entitled to veteran's disability compensation of 30% or more, or released from active duty for serviceconnected disability. Military veteran eligible for veteran s preference. Widow/widower of a military veteran eligible for veteran s preference. Spouse of an eligible military veteran with a service connected permanent and total disability. * Eligibility for veteran s preference is defined in RCW Applicants claiming veteran s preference eligibility may be required to provide a DD 214, NGB 22 or other documents to verify eligibility. Have you been employed by any other State of Washington agency? NO YES If yes, agency: Dates: Rev mw Page 5 of 5
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