Please print clearly and in ink. If you need assistance in completing this application, please let us know so that we can discuss a reasonable accommodation. RECRUITING DATA How did you hear about this position? Please check all that apply: College Website Higheredjobs.com NEHERC.com Personal referral Unsolicited Other: Position(s) for which you are applying: PERSONAL DATA Last Name: First Name: Middle: Street Address: City State: Zip: Preferred name or nickname: Mailing address (if different): Home phone number: ( ) Work phone number: ( ) Are you legally authorized to work in the United States? Yes No (Proof will be required at time of hire.) If applicable: Military Service Status: Active Inactive Branch: Are you now, or have you ever been, employed by a Mass. Community College, including MCC, State University or state agency? Yes No If yes, please answer the following questions: Are you currently working in a non-teaching position? Yes No If yes, at which institution? What is your position? Are you currently teaching full or part-time? Yes No If yes, at which institution? What is your position? How many credits are you teaching? Non-Credit Programs: Did you previously work at a State University or Community College in Massachusetts? Yes No If yes, at which institution did you work? When? What was your position? Did you work full-time and/or part-time? Are you a retiree from the Massachusetts State Retirement System? Yes No EDUCATION School Name City/State Course of Study Years Completed Diploma/Degree High School Undergraduate College Graduate/ Professional Other (Specify) Academic honors, awards or special recognition: Do you have any objection to our contacting your previous schools? Yes No If yes, please explain:
APPLICATION FOR EMPLOYMENT EMPLOYMENT/WORK HISTORY Please start with your present or most recent position. Include any military service assignments and verified volunteer activities. You may exclude organizations that indicate race, color, religion, sex, national origin or other protected status. You may attach a resume if you prefer and fill in only the information requested below that is not on your resume.
PROFESSIONAL REFERENCES Please list 3 professional references who can verify your work history and performance. References should not be relatives and at least two must have directly supervised you at some time in your work history. 1. Name of supervisor: Title: 2. Name of supervisor: Title: 3. Name of supervisor: Title: OTHER SKILLS Please indicate languages other than English that you speak, read and/or write: Fluent Good Fair Speak Read Write Please list any additional experiences, skills or qualifications that you believe would especially qualify you for employment at the College in the position(s) for which you have applied. Include any specialized training, apprenticeship, extra-curricular activities, and/or job-related training received in the United States military. If the space below is insufficient, please attach an additional page:
EMPLOYMENT DATA Date available for work: Total hours available per week: Do you have reliable transportation to/from work? Yes No It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. APPLICANT S STATEMENT Read carefully before signing: I certify that all information in this application for employment (which includes any resume incorporated by reference) are true and complete to the best of my knowledge. I authorize investigation of all information provided. I understand that this application is not and is not intended to be a contract of employment. In the event of employment, I understand that any material false or misleading information given in this application or interview(s) will result in immediate discharge. I understand that as a condition of employment at Middlesex Community College I may be required to pay union dues or an agency fee under the provisions of existing collective bargaining agreements covering some, but not all, positions at Middlesex Community College. I further understand that upon hire I am required to abide by all rules and regulations of the College. By checking this box I agree to the above statement. Signature of Applicant: Date: Middlesex Community College is an affirmative action/equal opportunity employer and does not discriminate on the basis of race, color, national origin, sex, disability, religion, age, veteran status, genetic information, gender identity or sexual orientation in its programs and activities as required by Title IX of the Educational Amendments of 1972, the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, Title VII of the Civil Rights Act of 1964, and other applicable statutes and college policies. The College prohibits sexual harassment, including sexual violence. Inquiries or complaints concerning discrimination, harassment, retaliation or sexual violence shall be referred to the College s Affirmative Action and/or Title IX Coordinator, the Massachusetts Commission Against Discrimination, the Equal Employment Opportunities Commission or the United States Department of Education s Office for Civil Rights.
Diversity & Equity Affairs/Affirmative Action SURVEY OF PARTICIPANTS VOLUNTARY SELF-DISCLOSURE FORM Middlesex Community College is committed to inclusive excellence and to the educational and workplace benefits of diversity. The College does not discriminate on the basis of race, color, national origin, sex, disability, religion, age, veteran status, genetic information, gender identity, or sexual orientation. As an equal opportunity employer, the College complies with state and federal affirmative action requirements. We ask that you provide this information for affirmative action purposes only. Please note that this information is not a part of your official application for employment. It is considered confidential, will be kept in a separate confidential file, and this form will not be disclosed to any search committee or hiring manager. SUBMISSION OF THIS INFORMATION IS VOLUNTARY. FAILURE TO SUBMIT THIS INFORMATION WILL NOT AFFECT YOUR APPLICATION. Please print your name. Last Name: First Name: Middle: Position(s) for which you are applying: 1) Sex: Male Female 2) What is your race/ethnicity? Please review all of the categories and definitions before completing this survey. If you choose to voluntarily self-identify, you may mark only one of the boxes presented below. Hispanic or Latino/a: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White: a person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American: a person having origins in any of the black racial groups of Africa. Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander: a person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. American Indian or Alaska Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Two or More Races: a person who primarily identifies with two or more of the above race/ethnicity categories. 3) Are you a veteran? Yes, I identify as one or more of the classifications of protected veterans defined below (disabled veteran, recently separated veteran, active duty wartime or campaign badge veteran, or Armed forces service medal veteran). Disabled Veteran is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability. Recently Separated Veteran means any veteran during the three-year period beginning on the date of such veteran s discharge or release from active duty in the U.S. military, ground, naval, or air service. Active Duty Wartime or Campaign Badge Veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. Armed Forces Service Medal Veteran means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. No, I am not a protected veteran. 4) Disability status? Yes, I have a disability. No, I don t have a disability. I don t wish to answer. This information is asked for affirmative action purposes only and will be sent to the College s Affirmative Action Officer. You are not required to provide this information prior to employment. Please send your completed survey to: Darcy Orellana, Affirmative Action Officer/Assistant Director Human Resources, Middlesex Community College, Cataldo Building, 591 Springs Road, Bedford, MA 01730 Signature Date