Palo Verde Community

PALO VERDE COMMUNITY

COLLEGE DISTRICT

Human Resources

POSITION APPLIED FOR:

TODAY’S DATE:

SOCIAL SECURITY #:

One College Drive

Blythe CA 92225

(760) 921-5500, ext. 5408

PART I Personal Information (Please type or print in black ink.)

NAME:

LAST, FIRST, MI

ADDRESS:

NUMBER & STREET, CITY, STATE, ZIP

TELEPHONE: HOME: WORK:

FAX NUMBER: E-MAIL ADDRESS:

FAX# (760) 922-0230

Thank you for your interest in employment at Palo Verde Community College District. The following is important information concerning the employment process.

Our employment application form is designed to assist the search committee in evaluating whether or not you possess the required knowledge and skills for the position for which you are applying. Job related information from all applicants will be evaluated to identify those best qualified. Only the best-qualified applicants will be selected for testing and further evaluation. Therefore, the application must be completed to allow a comprehensive review and evaluation. Failure to complete the application (and supplemental material, when required) will constitute failure to comply with the selection process and the application will be rejected.

1.  To guarantee consideration, a completed application and any other required material listed on the “Job Announcement”, must be received in the human resources office by the published closing date.

2.  Applications are only accepted for positions currently open for recruitment.

3.  Current employees who are applying for a position should be aware that material from their personnel files will not be included as part of the application packet, and they should, therefore, provide information on past and present employment in the same degree of detail as any other candidate.

4.  Applicants wishing to apply for more than one position must submit a separate application and required materials for each position. Legible photocopies of applications will be accepted only with an original signature and date.

5.  Complete all areas of the application. Do not write “See Resume”.

6.  Please read the job announcement/description carefully to insure your background meets the requirements of the position.

7.  It is the applicant’s responsibility to notify human resources of a change of address.

8.  Meeting minimum requirements does not guarantee an interview.

9.  Applicants should not expect official notification until the selection of the candidate has been completed and board approved.

10.  Please type or print (in ink) all information.

11.  The district reserves the rights to close, re-advertise, extend the recruitment period, or cancel filling a position at any time.

Pursuant to Title IX of the Education Amendments of 1972, Title VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and amendments and other laws, orders, and regulations governing discrimination, Palo Verde College is an equal opportunity employer and does not discriminate on the basis of race, color, national and ethnic origin, handicap, sexual orientation, sex, or age.

PART II – Education and Training (*PROOF OF DIPLOMA OR DEGREE AS REQUIRED)

High School / Technical School / College / Graduate
Check Highest Level Completed: / 1 2 3 4 / 1 2 3 4 / 1 2 3 4 / 1 2 3 4 5 6
High School: Earned Diploma: Yes No
*Year earned:
Address:
Street , City, St., Zip
Community College: Degree Earned: Yes No
*Year earned:
Address:
Street, City, St., Zip
Major/Concentration: Semester Units/Credits Earned:
College or University: Degree Earned: Yes No
*Year earned:
Address:
Street, City, St., Zip
Major/Concentration: Semester Units/Credits Earned:
Business/Trade/Technical School:
Address:
Street , City, St., Zip
Major/Concentration: Semester Units/Credits Earned:
*Year earned:

PART III - Licenses, Certifications and other pertinent information.

List any job related licenses and/or earned certificates.

List office equipment used, typing or shorthand speed, and languages spoken other than English:

PART IV - Employment History

REFERENCES: Please list three professional references that are familiar with your work related ability and background. Do not use relatives or friends unless you have a legitimate working relationship.

NAME / BUSINESS/OCCUPATION / TELEPHONE NUMBER
Name of present or most recent employer:
Employer address: / Telephone:
Position title: / Hours worked per week:
Dates of Employment: From (mo & yr) / To: (mo & yr)
Name of Supervisor: / Supervisor’s title:
Reason for leaving: / Pay Rate:
Summary of job duties:
Name of present or most recent employer:
Employer address: / Telephone:
Position title: / Hours worked per week:
Dates of Employment: From (mo & yr) / To: (mo & yr)
Name of Supervisor: / Supervisor’s title:
Reason for leaving: / Pay Rate:
Summary of job duties:
Name of present or most recent employer:
Employer address: / Telephone:
Position title: / Hours worked per week:
Dates of Employment: From (mo & yr) / To: (mo & yr)
Name of Supervisor: / Supervisor’s title:
Reason for leaving: / Pay Rate:
Summary of job duties:
Name of present or most recent employer:
Employer address: / Telephone:
Position title: / Hours worked per week:
Dates of Employment: From (mo & yr) / To: (mo & yr)
Name of Supervisor: / Supervisor’s title:
Reason for leaving: / Pay Rate:
Summary of job duties:

PART V - General Information

1. / Are you currently employed? Yes No
May we contact your employer? Yes No
May we contact your former employers? Yes No
2. / Have you ever worked for the Palo Verde Community College District? Yes No
If yes, under what name:
3. / Do you have relatives working for the Palo Verde Community College District? Yes No
If yes, give names, relationships, departments where they work:
4. / If you are not a U.S. Citizen, can you (if accepted for employment) provide proof of your legal right as a non-citizen to remain and work in the U.S.? Yes No
5. / Have you ever been convicted of a crime other than a minor traffic violation? (Note: Driving Under the Influence, reckless driving and hit-run driving are not considered minor traffic violations.) Yes No
If yes, list:
Were you convicted under another (maiden/alias) name? Yes No
If yes, give name:
Note: A conviction is not an automatic bar to employment unless the conviction is for a crime that would prohibit your employment under provisions of the California Education Code.

DISCLOSURE

The application form and all attached documents become official records of Palo Verde Community College District and cannot be returned. Please make a copy for your files before submitting. Applications for Palo Verde Community College District employment are subject to public disclosure laws and confidentiality of information contained therein cannot be assured.

You are not required to disclose information about physical or mental limitations that you believe will not interfere with your capability to do the job. Applicants needing assistance in the recruitment process due to a disability should submit a request to the human resources office at least ten days before the accommodation is needed.

APPLICANT CERTIFICATION AND AGREEMENT (Please read carefully before signing)

I hereby certify that all statements made on this application and supplemental materials are true and complete to the best of my knowledge. I understand that any false, incomplete or incorrect statements may result in my dismissal from employment with Palo Verde Community College District.

I authorize the district to investigate my references, work record, performance evaluations, education, or any other matters relating to my suitability for employment. I authorize and direct my former or current employers and educational institutions to release to Palo Verde Community College District any information they may have concerning me, whether or not it is in their records. I release the parties listed above from any and all liability related to this process of gathering information about my suitability for employment.

I understand that the work schedule and location may vary depending upon the needs of the district. The work location may include other off-site locations as assigned by the district.

Applicant’s Signature Date

PALO VERDE COMMUNITY COLLEGE DISTRICT

SUPPLEMENT TO APPLICATION FOR EMPLOYMENT

CONFIDENTIAL

TO THE APPLICANT: The information requested below is voluntary. You are not required to complete this form, nor will failure to complete it affect your application in any way.

Palo Verde Community College District subscribes to a policy of equal opportunity in employment. The College is required by Federal regulations to maintain records to monitor the effectiveness of its equal opportunity programs. This form will be maintained separately from the other application material and will be used for statistical record keeping only. If you have questions regarding the College's equal opportunity program, please contact the Affirmative Action Officer at the address below or call (760) 921-5348.

NAME OF APPLICANT:

ADDRESS (street, city, st., zip):

CURRENT DATE:

POSITION APPLIED FOR(title):

SEX: Male Female

BIRTHDAY: Month Day Year

RACE: American Indian/Alaskan Native

Asian American/Pacific Islander

Black

Filipino

Hispanic/Spanish Surname

White

Other:

(Please read other side of this form for further clarification on race/ethnic background)

HANDICAP: I am a handicapped individual. If checked, please specify handicap:

VETERAN

STATUS: I am a Veteran of the Armed Forces (Dates of Duty to .

I am a Disabled Veteran or a Veteran of the Vietnam Era as defined by the U.S. Department of Labor.

HOW DID YOU LEARN OF THIS JOB OPENING?

Newspaper Advertisement (Name of Publication)

Professional Organization (Name of Organization)

California State Dept. of Employment Development

College/University Placement Office

Personal Contact with College Employee

Personal Contact with Individuals not at the College

Other:

Return Form To: Affirmative Action Officer (or with application)

Palo Verde Community College District

One College Drive

Blythe, CA 92225

DEFINITIONS

RACE/ETHNIC ORIGIN: Designated race/ethnic origin categories are defined by the Equal Employment Opportunity Commission (29 CFR 1602) as follows:

a.  White (not of Hispanic origin) should include all persons having origins in any of the original peoples of Europe, North Africa, the Middle East.

b. Black (not of Hispanic origin) should include all persons having origins in any of the black racial groups.

c. Hispanic/Spanish Surname should include all persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

d. Asian American/Pacific Islander should include all persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.

Asian American: AC = Chinese AI = Asian Indian

AJ = Japanese AK = Korean

AL = Laotian AM = Cambodian

AV = Vietnamese AX = Other Asian

Pacific Islander: PG = Guamanian PH = Hawaiian

PS = Samoan PX = Other Pacific Islander

e. American Indian/Alaskan Native should include all persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

HANDICAP: A handicapped individual (Definition from Section 503, Rehabilitation Act of 1973, 41 CFR Part 60-741, Subpart A, Section 60-741.2) is any person who:

1. has a physical or mental impairment which substantially limits one or more of such person's major life activities;

2. has a record of such impairment or;

3. is regarded as having such impairment. A handicapped individual is "substantially limited" if he or she is likely to experience difficulty in securing, retaining or advancing in employment because of a handicap.

The legal requirements regarding the treatment of qualified handicapped individuals, also applies to qualified disabled veterans.

Information concerning individuals shall be kept confidential except that (i) supervisors and administrators may be informed regarding any necessary accommodations; (ii) first aid personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment, and (iii) government officials investigating compliance shall be informed.

7/01 (in compliance with state regulations)

PALO VERDE COMMUNITY COLLEGE DISTRICT

REFERENCE/ACKNOWLEDGEMENT WAIVER

Position for which you are applying:

I acknowledge that consideration for employment is contingent on the results of a reference and background check. Therefore, I hereby authorize the Palo Verde Community College District to:

(1) Investigate the truthfulness of all statements made on my employment application;

(2) Contact my former employers and other listed references or any other persons who can verify information (except, that the District agrees to contact me prior to contacting any persons employed at my current place of employment);

(3) Discuss the results of any investigation with other employees of the Palo Verde Community College District involved in the hiring process;

(4) Check my driving record, if applicable to the job for which I am applying.

In addition, I give my consent for all contacted persons including former employers to provide information concerning this application, and I release each such person from liability for providing information to the Palo Verde Community College District.

______

Signature Date

Please Print Name

Notice of Request for Verification of Employment

The following page contains the Request for Verification of Employment form. This form is required to verify previous Academic (teaching) employment or for Vocational Employment Verification. The verification will be used to assist the District in salary schedule placement.

This form will not be used unless you are invited for the Stage II (Face-to-Face) interviews.

Please make sure the information about employers on the application is complete with the phone numbers for the appropriate Human Resources Departments.

Please fill out Section I on the following page and return with Employment Application.

Application material will not be considered “Complete” if this signed form is not included.

PALO VERDE COMMUNITY COLLEGE DISTRICT

HUMAN RESOURCES

ONE COLLEGE DRIVE

BLYTHE CA 92225

760-921-5408

REQUEST FOR VERIFICATION OF EMPLOYMENT

Employment verification is required to assist the District in salary schedule placement. Signed authorization from the individual in question is below and on the attached Waiver.