Application for Employment s75

Application for Employment

IOWA CENTRAL COMMUNITY COLLEGE

One Triton Circle, Fort Dodge, IA 50501 · (515) 574-1138

*An Equal Opportunity/Affirmative Action Employer

This application is only for a specific position and will be kept on file for three years.

Please complete application in full and answer all questions completely. Type or print legibly. Indicate N/A if not applicable. Do not indicate, "see resume". A resume may be attached to provide additional supporting information. Incomplete applications may not be given consideration for employment. In order to be guaranteed consideration as an applicant, you must complete, sign, and return this form to the Human Resources office on or before the posted review date of the position for which you are applying.

An annual Campus Security Report is available to inform current and prospective employees about the college’s policies and programs to keep them safe. This report is available on our website and a paper copy is available upon request: http://www.iowacentral.edu/security/index.asp

Position(s) Applying For

PERSONAL INFORMATION

Name
(Last) / (First) / (Middle)
Address
(Street/P. O. Box) / (City) / (State, Zip)
Telephone
(Home) / (Cell)
E-mail

EDUCATION

Name and Address for each School Listed / Number of Years Completed / Diploma or Type of Degree Received
High School
Community College
College/University
Other Education
Other Education

Non-Discrimination Statement
It is the policy of Iowa Central Community College not to discriminate on the basis of race, color, national origin, sex, disability, age (employment), sexual orientation, gender identity, creed, religion, and actual or potential parental, family or marital status in its programs, activities, or employment practices as required by the Iowa Code §§ 216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681 – 1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), Age Discrimination Act of 1975 (34 CFR Part 110), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact Kim Whitmore, Director of Human Resources, phone number 515-574-1138, ; or the Director of the Office for Civil Rights, U.S. Department of Education, Citigroup Center, 500 W. Madison, Suite 1475, Chicago, IL 60661, phone number 312-730-1560, fax 312-730-1576.

EMPLOYMENT HISTORY

ENTER MOST RECENT JOB FIRST

Employer / Your Job Title / Date Started
MO. YR. / Date Left
MO. YR.
Employer's Address / Supervisor's Name / Starting Salary / Final Salary
Hours per Week Employed / Reason for Leaving / May we contact this employer (yes or no)?

Description of Duties and Responsibilities (in detail):

REFERENCES

Name three persons not related to you who have knowledge of your qualifications for this position:

Name and Address / Position / Telephone

JOB FUNCTIONS

Are you aware of any reason you cannot perform the functions of the job for which you are applying?
If yes, describe such reason:

JOB INTEREST

Do you wish to work full time, part time, or temporarily?
Date available for work:
Do you have commitments to another employer that might affect your employment with us?
If yes, please describe
What other position(s) are you qualified for?
Have you previously been employed by Iowa Central Community College (yes or no)?
If yes, when?
Are you legally authorized to work in the United States (yes or no)?
Are you over the age of 18 (yes or no)?

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge.

I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorize persons, schools, my current or previous employers, and other organizations named in this application (and accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision.

If offered a position with Iowa Central Community College, I consent to taking a physical examination; and I agree to conform to all policies, procedures, rules, and regulations of ICCC.

As an applicant I understand that according to the Iowa Smokefree Act of 2008, smoking is prohibited in any college building, vehicle, or on the college grounds, including parking lots.

Signature of Applicant / Date

IOWA CENTRAL COMMUNITY COLLEGE

QUESTION WHETHER APPLICANT HAS BEEN CONVICTED OF A FELONY

Have you been convicted of a felony?* (yes or no)
If yes, briefly explain as to the nature of the offense, when convicted, where convicted, and any participation in a rehabilitation program:

*A conviction record will not necessarily be a bar to employment, and factors such as age and time of offense, the seriousness and nature of the violation, the applicants rehabilitation, and the relevance of the convicted offense to the duties and responsibilities of the position for which applied will be considered in the hiring decision.

I hereby affirm that the information provided on the above is true and complete to the best of my knowledge.

Signature of Applicant / Date

IOWA CENTRAL COMMUNITY COLLEGE One Triton Circle Fort Dodge, IA 50501

IOWA CENTRAL COMMUNITY COLLEGE

JOB APPLICANT NOTICE OF WAIVER PROCEDURE TO

GRANT PERMISSION TO THE COLLEGE TO

CONDUCT BACKGROUND CHECK

Applicants considered for employment and employees are treated without regard to age, race, creed, color, sex, sexual orientation, gender identity, national origin, religion, disability, or military services. Iowa Central Community College complies with government regulations and affirmative action responsibilities. The Age Discrimination in Employment Act prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. The Iowa Civil Rights Act prohibits discrimination on the basis of age with respect to individuals who are at least 18 years of age and/or who are considered by law to be an adult.

The background check company, ADP Screening and Selection Services, will prepare the background report for Iowa Central. ADP Screening and Selection Services is located at 301 Remington Street, Fort Collins, CO 80524, and can be reached by phone at 800-367-5933 or at their Internet Web site address www.adpselect.com.

Solely for Iowa Central Community College to comply with requirements by the ADP Screening and Selection Services and its agents to conduct and provide to the College background information, we request that you complete and sign the following Waiver and return it to the College’s Human Resources Office.

The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, public, educational and, as appropriate, driving records checks.

We appreciate your cooperation.

I will provide to the College, when requested, the necessary information for the background check. By my signature on the completed Job Application Waiver, I will give permission to Iowa Central Community College to conduct a background check with ADP Screening and Selection Services.

I acknowledge receipt of this notice.

Signature of Applicant / Date

IOWA CENTRAL COMMUNITY COLLEGE One Triton Circle Fort Dodge, IA 50501

IOWA CENTRAL COMMUNITY COLLEGE

APPLICANT DATA RECORD

Applicants are considered for employment and employees are treated without regard to age, race, creed, color, sex, sexual orientation, gender identity, national origin, religion, disability, or military service.

Iowa Central Community College complies with government regulations and affirmative action responsibilities.

Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the following information. We appreciate your cooperation. This data is for analysis and affirmative action only, and it will be kept in a confidential file separate from the application for employment.

Please complete this form and return it to the Human Resources Office.

Date:

Position(s) Applied For:

Referral Source: Advertisement Friend Relative Walk-in

Employment Agency ICCC Employee Other

Check one: Female Male

Check one of the following:

Race/Ethnic Group: White _____ Black/African American

Hispanic/Latino _____ Native Hawaiian/

Other Pacific Islander

American Indian/Alaska Native _____ Two or more races

Asian