Faculty Application for Employment

FACULTY APPLICATION FOR EMPLOYMENT

Chapman University is an Equal Opportunity Employer, committed to providing career opportunities toall people, without

regard to race, color, religion, sex, age, national origin, sexual orientation,disability, or veteran status.

(Type or print all information in ink; attach additional sheets if necessary.)

Position

Applying For: ______Department: ______

Name: Last______Middle______First______

Address: ______

StreetCityState Zipcode

Home Telephone: ______Cellular Telephone: ______Email: ______

Do you now, or have you ever worked for Chapman University? ___yes ___no If, yes, provide job title, department and dates of employment.

Job Title: ______Department:______From:______To:______

Have you ever been employed using a different name? ___yes ___no If yes, specify______

If hired, can you submit proof within three days of employment of your legal right to work in the United States? __yes __no

Will you now or in the future require sponsorship for employment visa status? (e.g., H-1B, TN, F-1 using OPT, etc.) ___yes ___no

Have you ever been debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency or do you now have such actions under investigation, review or pending in any way? ___yes ___no If yes, please explain______

______

Have you ever held or applied for a professional license or registration? ___yes ___no If yes, what state(s) ______. Have you ever been disbarred, revoked, suspended, sanctioned, proposed for disbarment, revocation, suspension, sanction or declared ineligible for license or registration , or voluntarily resigned, relinquished or in any way terminated your license or registration due to a pending investigation or disciplinary action or do you now have such actions under investigation, review or pending in any way? ___yes ___no If yes, explain______
______

______

Have you ever been terminated from employment or resigned in lieu of termination?___yes ___no If yes,pleaseexplain ______

EducationName and Address of SchoolNo. of years Courses/MajorDegree Conferred

Undergraduate ______

Graduate

Master Level ______

Doctoral Level ______

Employment History

Please list all employers for the last ten years AND each prior position qualifying you for the position you are applying for:

Institution______Position______Rank______Dates______

Additional information may be required for final candidates

IMPORTANT! READ BEFORE SIGNING!

Applicant’s Statement

I hereby certify that the information contained in this application, and my attached Curriculum Vitae or Resume is true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or material omission of applicant information I submitted may result in failure to receive an offer or, if hired, in my dismissal from employment.

I authorize Chapman University and its agents to investigate my suitability for employment. I authorize the people, universities, schools, corporations or companies contacted by ChapmanUniversity or its agents to provide all pertinent information they may have, personal or otherwise. I release all parties and persons from any and all liability for any damages that may result from furnishing such information to ChapmanUniversity, or from the use or disclosure of such information by ChapmanUniversity, its agents, employees or representatives.

I understand that if offered a position I must be willing to be subject to a background investigation and that I will be required to sign a separate release for that investigation, I further understand that all offers of employment will be contingent upon the successful results of this background investigation process.

I hereby acknowledge that I have read the foregoing in its entirety, and understand it.

______

Applicant’s Signature Date

Rev. 9/10 Retention: 3 years from start date of successful applicant or 3 years from separation if hired.

01/01/18