CENTRALSTATEUNIVERSITY

An Affirmative Action and an Equal Opportunity Employer

Application for Employment

Instructions: Please print or type. Include any supplemental information that you feel would be helpful in our consideration of your qualifications.

Personal Information

Name:

Last First MI (Optional)
Address:
Street City State ZIP
Phone Information:
Home Phone: Work Phone: Cell Phone:
E-Mail Address:

Are there any additional names under which your employment records, educational records, references, and other application information may be verified? YES NO

If so, list the names:

Do you have a legal right to live and work within the United States? YES NO

Proof of citizenship or immigration status will be required upon employment.

Do you have a driver’s license? YES NO If no, are you willing to secure one? YES NO

Are you a former CentralStateUniversity Employee? YES NO If yes, please give dates and department:

Do you have a relative who is currently working at Central State University? YESNO

If yes, please give their relationship to you and their department:

Have you ever been convicted of a felony? YES NO

If yes, please explain and include name under which you were convicted:

Desired Employment

Date You can begin working:

Full Time Part Time Temporary Intermittent

Position Title: Department:

Education and Training

High School Attended:

Name City State

High School Diploma: YES NO GED: YES NO

Please list below all post high school education:

Name of
School or College / Location
(City, State) / Graduation
Date / Degree
Received / Major

Please list below any additional course work or training relevant to the position for which you are applying:

Skills and Proficiencies

Please list below your skills and proficiencies:

Office
Equipment / Computer &
Operating Systems / Computer Languages
& Software Packages / Special Equipment
Or Machinery

Please list below any additional skills and proficiencies relevant to the position for which you are applying:

Shorthand Speed w.p.m. Typing Speed w.p.m. Data Entry k.p.m.

Licenses, Registrations, and Certificates

Please list below all licenses, registrations and certificates:

Type of License
Or Certificate / Issuing State
Or Agency / License
Number / Expiration
Date
Driver’s
License
Chauffeur’s or
Commercial License
Technical
Certificate
Other ProfessionalLicense or Certificate (e.g. RN, LPN,)

Employment Background:Please provide all employment experience, starting with your most recent position. If more space is needed, please attach an additional sheet.

Employer:
Employer Name Department
Address: Phone:
Street City/ State
Immediate Supervisor:
Name Title
Position: Dates of Employment:
Title From (Mo/Yr) To (Mo/Yr)
Position Duties:
Salary: $ HR/YR Reason For Leaving:
Employer:
Employer Name Department
Address: Phone:
Street City/ State
Immediate Supervisor:
Name Title
Position: Dates of Employment:
Title From (Mo/Yr) To (Mo/Yr)
Position Duties:
Salary: $ HR/YR Reason For Leaving:
Employer:
Employer Name Department
Address: Phone:
Street City/ State
Immediate Supervisor:
Name Title
Position: Dates of Employment:
Title From (Mo/Yr) To (Mo/Yr)
Position Duties:
Salary: $ HR/YR Reason For Leaving:
Employer:
Employer Name Department
Address: Phone:
Street City/ State
Immediate Supervisor:
Name Title
Position: Dates of Employment:
Title From (Mo/Yr) To (Mo/Yr)
Position Duties:
Salary: $ HR/YR Reason For Leaving:

Professional References

Please list below any professional references who can attest to your professionalism and work abilities.

Name / Address / Phone / Relationship to You

EEO Policy:CentralStateUniversity maintains a policy of non-discrimination for all employees and applicants. In compliance with federal and state laws, CentralStateUniversity hires, trains, and promotes all qualified employees without unlawful discrimination on the basis of race, color, sex, age, religious creed, marital status, citizenship, national origin or disability. This policy also applies to disabled veterans of the Vietnam Era.

Certification: I certify that the answers I have made to all of the questions in this application are true and complete to the best of my knowledge and belief. I understand that any misrepresentation or omission of material fact on this or any record submitted pertinent to employment will constitute grounds for immediate dismissal. I understand that if this application is not completed in its entirety, it will not be processed and I will be automatically disqualified. I understand that I am responsible for the correctness of this application. I understand and agree that this application is not a contract. I understand that a background check may be required prior to employment, and that in accordance with the Drug-Free Workplace Program, drug testing may be required. I waive all provisions of law forbidding colleges or universities which I attended, or past employers, from disclosing any information which they acquired relevant to my employment. I consent that they may disclose such information to Central State University Human Resources and/or the agency that holds the vacancy for which I am applying and to appropriate officials for recruitment purposes. I understand that any offer of employment is conditional upon proof of legal authorization to work in the United States as required by the Immigration Reform and Control Act.

I certify that I have read, understand, and will adhere to the aforementioned statements.

______

Applicant’s Signature Date

CENTRAL STATE UNIVERSITY POLICE AND SAFETY

Background Investigation Authorization and Release

I authorize Central State University to conduct a background check on me. I understand that such an investigation may include information as to my character, employment, education, driving, credit, and criminal history.

According to the Fair Credit Report Act, I will be notified by Central State University if employment is denied because of information obtained from a Consumer Reporting Agency.

I further understand and waive my right of privacy in this pre-employment investigation.

I hereby release Central State University and its agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above-mentioned information or reports.

Current Information

First Name: / MI: / Last Name:
Address:
City: / State: / Zip:
Social Security Number: / Drivers License Number/ State:
Date of Expiration: / Date of Birth:

Please provide all residential addresses for the past 5 years:

Street: / City/ State: / County:
Street: / City/ State: / County:
Street: / City/ State: / County:
Street: / City/ State: / County:
Street: / City/ State: / County:

A copy of this authorization shall be considered as valid as the original.

Date:
Applicant’s Signature:

APPLICANT SURVEY

NOTE: We request the information below in order to assist our equal employment opportunity efforts. This survey is voluntary. This survey will be processed separately and the information used for statistical purposes only.

Name______Date______

Street Address______

City, State, Zip______

Position you are applying for______

How did you learn about this position?

Newspaper

Vacancy Posting CSU Bulletin Board

CSU Job Line Posting

Electronic/computer posting

Centralized Recruitment Office

Other______

Race/ Ethnicity:

□Nonresident Alien

□Race and Ethnicity unknown
□ Hispanics of any race

For non-Hispanics only:
□ American Indian or Alaska Native

□ Asian

□Black or African American

□ Native Hawaiian or Other Pacific Islander
□ White
□ Two or more races

DISABILITY:

Do you have a physical or mental impairment, which substantially limits one or more of your major life activities?

Yes

No

VETERAN STATUS:

Are you a veteran?

Yes

No

Disabled Veteran

Vietnam Era Veteran

Desert Storm/Shield Veteran

SEX

Male

Female

DATE OF BIRTH: ______/______/______

Month Day Year

Rev. 06/07 -HR-05-2007-01-