Name: (LAST) (FIRST) (MIDDLE)
Mailing Address: STREET, PO BOX
(CITY) (STATE) (ZIP CODE) / Home Phone: Home Phone:
Work Phone: Work Phone:
Email: Enter Email / FOR OFFICIAL USE ONLY
Class Code: ______
Class Title: ______
Reviewed by: ______
CCSNH Location:______
Accepted Rejected Date: ______
Reason: ______
Internal announcement Yes No
/ COMMUNITY COLLEGE SYSTEM OF NEW HAMPSHIRE
The CCSNH is an equal opportunity employer. Discrimination on the basis of age, sex, race, color, religion, national origin, disability, genetic information, veteran status, marital status, sexual orientation, political affiliation, or any other non-merit factor is strictly prohibited.


Position for which you are applying: Position name / Position Number: If known
College / Location where position is located: College /Location
PLEASE RETURN APPLICATION
TO THE RECRUITING LOCATION
ADDRESSES ARE AVAILABLE
ON OUR WEBSITE:
/
RECRUITMENT/EMPLOYMENT SURVEY
I learned of this career opportunity through:
College/CCSNH website
News paper(Name)
Job Announcement
Job Fair
N.H. Employment Security
Other(Please explain)

EDUCATION

Please check the highest school grade completed: 8 9 10 11 12 13 14 15 16 17 18

Are there any specialized courses you have taken that you want to be considered in reviewing this application? Please explain below

Click here to enter text.

If the position for which you are applying requires postsecondary education credits or an earned educational degree,
YOU MUST SUBMIT official COPIES OF COLLEGE, BUSINESS, TRADE SCHOOL, AND/OR OTHER EDUCATION TRANSCRIPTS.
Name of School: Name of School: / Major: Major: / Degree: Degree or Certificate earned:
Name of School: Name of School: / Major: Major: / Degree: Degree or Certificate earned:
Name of School: Name of School: / Major: Major: / Degree: Degree or Certificate earned:
LICENSESAND CERTIFICATION
Pleaselistanylicenseorspecialcertificationthatyouhold,specifyinglicense/certificatenumberanddateofexpiration:
CDL# CDL# Class: Class: / Expires: Expires: / LPN# LPN# / Expires: Expires:
PE/EIT# PE/EIT# / Expires: Expires: / RN# RN# / Expires: Expires:
Other: Other: / Expires: Expires: / Other: Other / Expires: Expires:

(Unless prohibited by law, please include with your application a photocopy of any license or certificate.)

In order to receive credit for certification, you must submit proof of course completion and the certificate you earned.

Did you complete the WorkReadyNH program? Yes No Date: Date Location: Location
NCRC Level: Platinum Gold Silver Bronze


EXPERIENCE – WORK HISTORY

In the sections below, please describe your experience/work history (including pertinent volunteer experience), beginning with your current or most recent position. You should emphasize work experience most pertinent to the position for which you are applying. If more space is needed, please attach additional sheets. You are encouraged to submit acurrent résumé with your application.

PLEASE NOTE: RÉSUMÉS WILL NOT BE ACCEPTED IN PLACE OF A FULLY COMPLETED APPLICATION FORM.

Employer: Employer / Address: Address / Phone: Phone
Your Job Title: Job Title / Supervisor’s Name/Title: Name/Title
Dates of Employment: From Mo.Year To: Mo. Year Hours Worked Per Week: Hours worked May we Contact: YesNo
Specific Duties (Please describe the duties you performed in this position): Click here to enter text.
How many employees did you supervise? Enter text. Did you assign work? Yes No Did you reject unsatisfactory work? Yes No
Did you have the authority to hire/fire? Yes No Reason you left this position: Reason you left
Employer: Employer / Address: Address / Phone: Phone
Your Job Title: Job Title / Supervisor’s Name/Title: Name/Title
Dates of Employment: From Mo.Year To: Mo. Year Hours Worked Per Week: Hours worked May we Contact: Yes No
Specific Duties (Please describe the duties you performed in this position): Click here to enter text.
How many employees did you supervise? Enter text. Did you assign work? Yes No Did you reject unsatisfactory work? Yes No
Did you have the authority to hire/fire? Yes No Reason you left this position: Reason you left
Employer: Employer / Address: Address / Phone: Phone
Your Job Title: Job Title / Supervisor’s Name/Title: Name/Title
Dates of Employment: From Mo.Year To: Mo. Year Hours Worked Per Week: Hours worked May we Contact: Yes No
Specific Duties (Please describe the duties you performed in this position): Click here to enter text.
How many employees did you supervise? Enter text. Did you assign work? Yes No Did you reject unsatisfactory work? Yes No
Did you have the authority to hire/fire? Yes No Reason you left this position: Reason you left
Employer: Employer / Address: Address / Phone: Phone
Your Job Title: Job Title / Supervisor’s Name/Title: Name/Title
Dates of Employment: From Mo.Year To: Mo. Year Hours Worked Per Week: Hours worked May we Contact: Yes No
Specific Duties (Please describe the duties you performed in this position): Click here to enter text.
How many employees did you supervise? Enter text. Did you assign work? Yes No Did you reject unsatisfactory work? Yes No
Did you have the authority to hire/fire? Yes No Reason you left this position: Reason you left

I have attached a copy of my current résumé.

IFYOUHAVEEVERBEENCONVICTEDOFACRIME(FELONY ORMISDEMEANOR) THATHASNOTBEENOFFICIALLYANNULLEDBYACOURT,

YOU MUSTCOMPLETE THE FOLLOWINGSECTION, GIVINGTHE DATE,LOCATIONAND NATUREOFTHE FELONYOR MISDEMEANORCONVICTION.

IF YOU LEAVETHIS SPACEBLANK,YOU ARECERTIFYING THATYOU HAVENOCURRENT RECORD OFCONVICTION.

Click here to enter text.

Please Note: Convictionis not an automaticdisqualifier for employment.Eachcaseisconsideredindividually.

WILLFULOMISSIONORMISREPRESENTATIONOFREQUIREDINFORMATIONWILLBEABASISFORREJECTIONOFYOURAPPLICATION.

Iunderstandthatinorderformyapplicationtobeconsidered,theAffirmationbelowmustbecompleted.
Icertifythattheinformationprovidedin orattachedtothisapplicationis complete,accurate,andup-to-dateonthedate specifiedbelow.IcertifythatIhavethelegalrighttoaccept employment intheUnitedStates,andthatIwillproduce,atorbeforethedateofhire,proof oftherighttoacceptemployment.Ifurthercertify thattherearenowillfulmisrepresentations oftheabovestatementsandanswerstoquestionsherein,andthatIhavemadenoomissionsofmaterialfactwithrespecttoanyofmyanswerstothequestionspresented.Iunderstand that ifaninvestigationshould disclosesuchmisrepresentationoromissions, myapplicationmaybe rejected.Finally,Iunderstand that ifIshould beemployedatthetimeofsuchinvestigationand disclosure,myservicesmaybeterminatedimmediately.
Signature: Signature of Applicant: Date: Date:

Clicking this checkbox indicates that my name above represents my actual signature.

You may save this completed application form to your computer and attach it to an email to the college or location with the open position.