POSITION APPLIED FOR:

Cerritos College

11110 Alondra Blvd.

Norwalk, CA 90650-6298

TYPE OF EMPLOYMENT APPLIED FOR:
Full-time Part-time

(562) 860-2451

www.cerritos.edu

Academic Application for Employment

The District is strongly committed to achieving staff diversity and the principles of equal opportunity employment. The District encourages a diverse pool of applicants and does not discriminate on the basis of race, color, national origin, ancestry, sex, age, religion, marital status, disability, or sexual orientation in any of its policies, procedures or practices.

Last Name / First Name / Middle / Date:
Address / City / State / Zip / Home Telephone:
Email Address: / Work Telephone:
Driver’s License Number (if required by position) / Expiration Date / State / Cell/Mobile Telephone:

EDUCATIONAL BACKGROUND: List all accredited post-secondary educational institutions attended

College and Universities
Name of Accredited Institution / State / Major / Dates of Attendance / Units Completed (semester or quarter units) / Degree (AA, BS, MA, etc) / Date Granted
From: / To:

CREDENTIALS,CERTIFICATES, OR LICENSES:

Type of Credential, Certificate, or License / State / Subject Area/Discipline / Date Issued / Date Expires

FLUENCY IN LANGUAGES OTHER THAN ENGLISH:

Indicate level of proficiency: Basic (B), Fluent (F)
Language / Read / Write / Speak / Language / Read / Write / Speak

TEACHING OR OTHER EDUCATIONAL EXPERIENCE: List most recent experience first.

Dates of Employment / Name of Institution / City/State / Position
From:
To: / Salary (Hourly/Monthly) / Supervisor Name / Area Code/Telephone
Courses Taught / Full-time
Part-time
Hours per week:
Substitute
Reason for Leaving
Dates of Employment / Name of Institution / City/State / Position
From:
To: / Salary (Hourly/Monthly) / Supervisor Name / Area Code/Telephone
Courses Taught / Full-time
Part-time
Hours per week:
Substitute
Reason for Leaving
Dates of Employment / Name of Institution / City/State / Position
From:
To: / Salary (Hourly/Monthly) / Supervisor Name / Area Code/Telephone
Courses Taught / Full-time
Part-time
Hours per week:
Substitute
Reason for Leaving
Dates of Employment / Name of Institution / City/State / Position
From:
To: / Salary (Hourly/Monthly) / Supervisor Name / Area Code/Telephone
Courses Taught / Full-time
Part-time
Hours per week:
Substitute
Reason for Leaving
Dates of Employment / Name of Institution / City/State / Position
From:
To: / Salary (Hourly/Monthly) / Supervisor Name / Area Code/Telephone
Courses Taught / Full-time
Part-time
Hours per week:
Substitute
Reason for Leaving

OCCUPATIONAL EXPERIENCE: List most recent experience first.

Dates of Employment / Company Name / City/State / Position
From:
To: / Salary (Hourly/Monthly) / Supervisor Name / Area Code/Telephone
Major Duties / Full-time
Part-time
Reason for Leaving / Hours per week:
Dates of Employment / Company Name / City/State / Position
From:
To: / Salary (Hourly/Monthly) / Supervisor Name / Area Code/Telephone
Major Duties / Full-time
Part-time
Reason for Leaving / Hours per week:

MAY WE CONTACT YOUR CURRENT AND/OR PREVIOUS EMPLOYER(S) REGARDING YOUR QUALIFICATIONS AND/OR TEACHING/WORK PERFORMANCE:

Current: Yes No Previous: Yes No

LIST ANY OTHER EXPERIENCE THAT YOU BELIEVE CONTRIBUTES TO YOUR QUALIFICATIONS FOR THIS POSITION: (Include any volunteer experience)

WORK REFERENCES: In addition to current or former supervisors, you may list additional work references. Do not include relatives.

Name / Title / Phone
Company / Address, City, State and Zip Code
Name / Title / Phone
Company / Address, City, State and Zip Code
Name / Title / Phone
Company / Address, City, State and Zip Code
Name / Title / Phone
Company / Address, City, State and Zip Code

GENERAL INFORMATION:

Have you ever been employed by Cerritos College? / Yes No / If yes, when?
Do you have the legal right to work in the United States? / Yes No / If not, explain
Have you ever been discharged or forced to resign from any position? Yes No
Discharge from employment will not automatically disqualify you from employment, but failure to list all discharges may result in disqualification or dismissal. If your answer is yes, you must complete attached DISCHARGE STATEMENT FORM.
Have you ever been convicted of a criminal offense? Yes No
If yes, complete attached RECORD OF CONVICTION FORM.
You must answer YES if you were convicted, whether by plea, or jury verdict, or finding of guilt by a court in trial without a jury, irrespective of a subsequent order under Penal Code §1203.4 allowing the withdrawal of a plea of guilty and entering a plea of not guilty, or setting aside a verdict of guilt, or dismissing the accusations or information (you may omit minor traffic violations). A criminal record will not automatically disqualify you for employment, but failure to disclose a conviction record may result in disqualification or dismissal.
Do you have any relatives, by blood or law, who are currently employed by Cerritos College?
Name / Relationship / Title / Department

APPLICANT CERTIFICATION AND WAIVER:

I certify that the information I have provided in applying for this job is true and complete to the best of my knowledge and belief. I give Cerritos College and its authorized agents permission to verify and/or disclose any information given in connection with this application for personnel/employment purposes. I acknowledge that any misstatement or omission in the application materials may be cause for elimination from further consideration or dismissal if hired. I hereby authorize any and all persons and agencies to furnish to Cerritos College any information, including documents in my personnel file, which may be necessary to verify this application and any other materials submitted, and hereby waive any rights of privacy to the information or documents which I may have under any federal, state, or local law, ordinance or rule. I also understand that an incomplete application packet may delay or prevent opportunities with CerritosCollege.

Applicant’s Signature: ______Date: ______

Cerritos College is an Equal Opportunity Employer with a commitment to provide equal opportunity for all without regard to race, religion, national origin, sex, age, handicap, medical condition or Vietnam era veteran status. CerritosCollege complies with Title IX Educational Amendment of 1962 prohibiting sex discrimination in education. If you have a disability, and require accommodation to complete this application, contact the Human Resources office. Cerritos College employs only individuals lawfully authorized to work in the United States. Cerritos College does not provide sponsorship for changes in immigration status for the purpose of employment in the United States.

HR011910-AC

CerritosCollege

11110 Alondra Blvd.

Norwalk, CA90650-6298

(562) 860-2451

www.cerritos.edu

TO:APPLICANT

FROM:HUMAN RESOURCES DEPARTMENT

SUBJECT:APPLICANT DIVERSITY SURVEY (OPTIONAL)

Thank you for your interest in employment with the Cerritos Community College District. After your application has been received by the Human Resources Department, it will be considered in the course of the normal selection procedure.

Federal and State mandates require our institution to compile data on the sex, age, ethnicity, disability, and veteran status of applicants for employment opportunities. To assist us in complying with this requirement, we are requesting that you complete and return the Applicant Diversity Information Survey form on the reverse side.

This information will be used to evaluate the effectiveness of our recruitment efforts. It should be emphasized that it is the policy of the Cerritos Community College District to hire solely on the basis of the applicant’s qualifications in relation to the requirements and selection criteria for the particular position. Information obtained from the applicant on this survey is not provided to the selection committee responsible for making employment recommendations.

It should be understood that you have the option of providing or not providing the information requested, and that your decision in this matter will not affect the status of your application. Your cooperation in completing the survey is appreciated.

Please complete the Applicant Diversity Information Survey on the reverse side and return it with your application to the following address:

Human Resources

Cerritos Community College District

11110 Alondra Boulevard

Norwalk, CA90650

Cer

CerritosCollege

11110 Alondra Blvd.

Norwalk, CA90650-6298

(562) 860-2451

www.cerritos.edu

Applicant Diversity Survey (Optional)

Supplemental Equal Employment OpportunityApplication Information

Last Name / First name / Middle
Position applied for:
GENDER: Male
Female / AGE: 40 years or over
Below 40 years / VIETNAM ERA VETERAN (August 4, 1964 - May 5, 1975)
No Yes

ETHNIC GROUP (with which you most closely identify):

American Indian or Alaskan Native / Asian or Pacific Islander
Japanese / Guamanian / Asian Indian
African American/Black / Chinese / Samoan / Filipino
Korean / Laotian / Hawaiian
Caucasian/White / Vietnamese / Cambodian / Asian Other
Pacific Islander Other
Hispanic/Latino
Mexican, Mexican-American, Chicano / Mixed Ethnic (Please specify the ethnic groups)
Central American
South American
Hispanic Other

DISABILITIES - Physical or mental impairment that limits one or more major life activities; has a record of such an impairment; or is regarded as having such an impairment.

None Yes, please identify:

How did you hear about this vacancy?

Which newspaper, website, journal, etc.?
Vacancy notice, bulletin board – where posted?
Cerritos College employee – who?
Other (please specify)

Applicant’s Signature: ______Date:

Cerritos College

Last Name / First Name / Middle
Position applied for:

11110 Alondra Blvd.

Norwalk, CA90650-6298

(562) 860-2451

www.cerritos.edu

Record of Conviction

Supplemental Employment Application Information

Submit with Application only if Necessary

Because of our responsibility to students and to the public, it is important to be extremely careful in screening applicants with conviction records. You may be disqualified from consideration for, or dismissed from employment with CerritosCollege unless you fill out this form accurately and completely. In accordance with District policies, procedures, and the provisions of the Education Code, all prospective employees are fingerprinted and the fingerprints are submitted for verification.

Have you ever pled guilty, been convicted, fined, imprisoned, placed on probation or given a suspended sentence in court? In answering this question, you must include all sex offenses and controlled substance offenses even if they have been set aside by Penal Code section 1203.4, but you may omit minor traffic infractions. / No Yes (please complete information below)
A criminal record will not automatically disqualify you from your employment, but failure to list all convictions may result in disqualification or dismissal

INSTRUCTIONS: In the space below, give complete details for every time you have pled guilty, been convicted, fined, imprisoned, placed on probation, or given a suspended sentence in court. Please indicate if the situation was a misdemeanor or felony offense. If you are in doubt, list the conviction and explain. Do not include minor traffic infractions where the fine was $300 or less. For additional space, use a separate sheet.

Offense
(Brief Description) / Offense Code No.
(if known) / Date
Mo/Yr / Location
(City & State) / Disposition (imprisonment, fine, probation, suspended sentence) / Misd* / Flny*

* Misd = Misdemeanor Flny = Felony

Are you currently out on bail or released on your own recognizance pending trial regarding a criminal matter? / No Yes (please complete information below)

INSTRUCTIONS: In the space below, give complete details regarding the criminal matter(s) for which you are currently out on bail or released on your own recognizance. For additional space, use a separate sheet.

Offense
(Brief Description) / Offense Code No.
(if known) / Date
Mo/Yr / Location
(City & State) / Disposition (imprisonment, fine, probation, suspended sentence) / Misd* / Flny*

* Misd = Misdemeanor Flny = Felony

DECLARATION:I declare under penalty of perjury under the laws of the State of California that the information listed above is true and complete.

Applicant’s Signature: ______Date: ______

Last Name / First Name / Middle
Position applied for:

CerritosCollege

11110 Alondra Blvd.

Norwalk, CA90650-6298

(562) 860-2451

www.cerritos.edu

Applicant Request for Equivalency

Supplemental Employment Application Information

COMPLETE THIS FORM ONLY IF YOU DO NOT MEET THE MINIMUM QUALIFICATIONS
Please note that an applicant to teach, or be employed in, a Discipline that requires a Master’s Degree must have been awarded a Master’s Degree in any subject area as a basic requirement for consideration of an equivalency request.

INSTRUCTIONS: Complete each section of the form in detail to provide sufficient information related to your academic and teaching/occupational background. It is the applicant’s responsibility to provide complete information and documentation that supports his/her Application for Equivalency (unofficial transcripts, experience, training, etc.)

Describe your ACADEMIC background:
Associate’s degree in / Bachelor’s degree in
Master’s degree in / With emphasis and/or certificate in
Credential/Certificates
Other
(Attach a list of all coursework that you wish to be considered equivalent to the required degrees stated on the job announcement.)
WORKSHOPS, SEMINARS, OTHER TRAINING attended that apply to the field or discipline in which the equivalency is requested:
Describe your TEACHING/OCCUPATIONAL experience to be considered as equivalent to the qualifications required for the job:
Provide any additional information to support application for equivalency:

Applicant’s Signature: ______Date: ______

FOR INTERNAL USE ONLY  Approved  Denied Date ______
Hiring Standard Committee Chair (name)______Signature: ______

Cerritos College

11110 Alondra Blvd.

Norwalk, CA90650-6298

(562) 860-2451

www.cerritos.edu

Discharge Statement

Supplemental Employment Application Information

Submit with Application only if Necessary

Last Name / First Name / Middle
Position applied for:
Have you ever been discharged or resigned to avoid discharge from any position? Yes No
Discharge from employment or forced resignation will not automatically disqualify you from employment, but failure to list all discharges or forced resignations may result in disqualification or dismissal from employment.

INSTRUCTIONS: In the space below, give complete details for every time you were discharged or forced to resign from any position.

DECLARATION:

I declare under penalty of perjury under the laws of the State of California that the information listed above is true and complete.

Applicant’s Signature: ______Date: ______

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