Pierce College District

Human Resources

9401 Farwest Drive SW.Email:

Lakewood, WA 98498-1999Telephone: (253) 964-6579

WEB: http://www.pierce.ctc.edu Fax:(253) 912-3638

TDD: (253) 964-6228

This application must be filled out completely, typed or printed in blue or black ink, and signed.

Position for which you are applying:

/ Recruitment Number:
Type of employment you are willing to accept:
Full-time Part-time Hourly / Shifts:
Day Afternoon/Evening Night

PERSONAL DATA

Name: / Former name(s) under which you have been employed:
Street Address:
City, State, Zip Code:
Home Telephone: ( ) / Other Contact:
Telephone: ( ) / E-mail Address:
Are you currently a permanent classified employee of a state agency or public higher education institution in Washington? Yes No / Can you provide proof of United States citizenship or authorization to work in the United States? Yes No

EDUCATION

Have you graduated from high school or received a GED certificate? Yes No
College or University / City, State / From Mo/Yr / To
Mo/Yr / Total Credits Earned / Degree, Diploma or
Certificate / Major or Subject
Taken
/ Sem
Qtr
Sem
Qtr
Sem
Qtr
Technical, trade, business or other school / City, State / From Mo/Yr / To
Mo/Yr / Total Credits Earned / Degree, Diploma or
Certificate / Major or Subject
Taken
Sem
Qtr
Sem
Qtr
Sem
Qtr
SKILLS: List office, computer and trade skills, or other skills pertinent to the position for which you are applying.
LICENSES, PERMITS AND CERTIFICATES: (Relevant to position)
EMPLOYMENT HISTORY
List most recent experience first. Include military service experience and non-paid experience, which is related to the job for which you are applying. Submitting a résumé is optional. A résumé cannot be used to replace the Employment History portion of this application form.
Employer: / Job Title:
Street Address: / Duties:
City/State/Zip:
Immediate Supervisor:
Telephone: ( )
E-mail: / Dates of Employment: From: (mo/yr) To: (mo/yr)
Reason(s) for Leaving / Salary: / Hours per week:
Employer: / Job Title:
Street Address: / Duties:
City/State/Zip:
Immediate Supervisor:
Telephone: ( )
E-mail: / Dates of Employment: From: (mo/yr) To: (mo/yr)
Reason(s) for Leaving / Salary: / Hours per week:
Employer: / Job Title:
Street Address: / Duties:
City/State/Zip :
Immediate Supervisor:
Telephone: ( )
E-mail: / Dates of Employment: From: (mo/yr) To: (mo/yr)
Reason(s) for Leaving / Salary: / Hours per week:
NOTE: If you need to list more than three employers, please attach additional sheets.
PROFESSIONAL REFERENCES – Include those work colleagues who have first hand knowledge of your skills and abilities. (Do not include personal friends or relatives)
Name: / Telephone Number: ( )
Official Position & Employer:
Name: / Telephone Number: ( )
Official Position & Employer:
Name: / Telephone Number: ( )
Official Position & Employer:
NOTE: If you need to list more than three professional references, please attach additional sheets.
VETERAN'S PREFERENCE
Veterans, widows/widowers of veterans and spouses of veterans who wish to receive veteran’s preference must complete and attach the "Request for Veteran's Preference”
form when applying for classified positions.
PLEASE READ CAREFULLY
An applicant’s criminal conviction record as it relates to job performance may be considered as allowed under state law. Once a conditional offer of employment has been made to an applicant, the College may perform background checks.
Have you been convicted of a felony within the last ten years?
Yes No
If yes, please describe:
A conviction record will not automatically disqualify you for employment unless such record would reasonably affect your fitness for the position for which you have applied.
APPLICANT'S CERTIFICATION AND AGREEMENT
Please read carefully
I hereby authorize Pierce College to make inquiries regarding my education, work experience and references. I hereby release all parties and persons associated with
any such inquiries from liability in connection with furnishing this information.
I understand that should my position include security clearances, significant money handling, unsupervised access to children under the age of 16, developmentally disabled
persons, vulnerable adults, or if I am provided with multiple key / card access to buildings, classes and facilities, I will consent to a background investigation to check information
contained in or related to my application, including records of law enforcement agencies.
If I am offered employment, I understand that employment will be on a conditional basis pending completion of the background check. I understand that should investigation
disclose misrepresentation or omission, such disclosure will constitute grounds for withdrawal of employment offer, rejection of application, or dismissal.
I certify that the information provided in this application including attached documents is true, correct and complete to the best of my knowledge. I understand that
consideration of this application and the continuation of any employment gained, depend upon the true and accurate representation of the facts as stated or implied
in this application.
Signature ______Date ______
NOTE: If submitting your application form by email and you are selected for an interview, you will be required to sign your application at the time of the interview.
It is the policy of Pierce College to provide equal employment opportunity in all terms and conditions of employment for all persons without regard to race, color,
creed, religion, national origin, sex, sexual orientation, age, marital status, presence of sensory, mental or physical disability, or disabled or Vietnam-era veteran.

An Equal Opportunity/Affirmative Action Employer

Revised 8/03/2007

PIERCE COLLEGE

VOLUNTARY INFORMATION

Position Applied For: Name: Date:

The college requests that you provide the following information.

REFERRAL SOURCE: How were you referred to Pierce College?

Newspaper in print: (which) ______State Employment Office

Internet Source (which one?): ______Public Agency (which one?)

Job Fair (which one?) ______Other source: (specify)

AFFIRMATIVE ACTION:

Pierce College is committed to an Affirmative Action Program which provides for the recruitment of women, persons of color, individuals with disability, aged, special disabled veterans and veterans of the Vietnam era, in job categories in which they may be under-represented. To implement this program more successfully. Completion of this section is completely VOLUNTARY, will be considered confidential and will be filed separately from the main application form. Refusal to provide any information requested on this form will not in any way subject you to any adverse treatment.

Birthdate: ______Sex: Male Female

Which race do you consider yourself to be? (Note: computer system accepts only one race code)

White (800) Black or African-American (870) Korean (612)

American Indian (Print name of enrolled or principal tribe) ______

Eskimo (935) Aleut (941) Asian Indian (600) Vietnamese (619) Guamanian (660)

Chinese (605) Filipino (608) Hawaiian (653) Samoan (655) Japanese (611)

Other Asian or Pacific Islander (Please specify) ______

Other Race (Please specify) ______

Multi-Racial (If you have indicated multi-racial, please choose one preference for Affirmative Action purposes) ______

Are you or are you not of Spanish/Hispanic origin? (Note: computer system accepts only one code)

No, not Spanish/Hispanic (999) Yes, Puerto Rican (727) Yes, Cuban (709)

Yes, Mexican, Mexican-Am., Chicano (722) Yes, other Spanish/Hispanic (Please specify)

Do you have a disability? “Disability” means the presence of a sensory, mental, or physical impairment that: is medically cognizable or diagnosable; exists as a record or history; is perceived to exist whether or not it exists in fact. Yes No

If you are a VETERAN, please check all boxes that apply:

Veteran Status:
Special Disabled Veteran / Definition: a person entitled to disability compensation under laws administered by the US Dept. of Veteran Affairs for disability rated at 30% or more, or rated at 10% or 20% if determined to have a serious employment handicap, or a person whose discharge or release from active duty was for a service-connected disability.
Vietnam-Era Veteran / Definition: a person who served on active duty for a period of more than 180 days, any part of which occurred (1) between February 28, 1961 and May 7, 1975 in the case of a veteran who served in the Republic of Vietnam, or (2) between August 5, 1964 and May 7, 1975 in all other cases AND was discharged or released from duty with other than a dishonorable discharge. The term also refers to a person who was discharged or released from active duty for a service-connected disability if any part of such active duty was performed in the Republic of Vietnam during the same time periods listed above.
Other Veteran / Definition: a person who served on active duty during a war, OR served in a campaign or expedition for which a campaign badge, service medal or an expeditionary medal has been awarded. To identify the campaigns and expeditions that meet this criterion, see the listing on the reverse side of this page.
Newly Separated Veteran / Definition: a veteran who has served on active duty in the U.S. Military, guard, naval or air service and who has been discharged or released within the last year from the date of this application.

Revised 7/25/2007

CAMPAIGN/EXPEDITION DATESORGANIZATIONS PARTICIPATING

StartEndArmyNavy Air Force Marine Corp Coast Guard

Campaign or Service Medals

American Defense Service9/8/3912/7/41XX---X X

Army Occupation of Austria5/9/457/27/55X---X------

Army Occupation of Berlin5/9/4510/2/90XXXXX

Army Occupation of Germany5/9/455/5/55XXX---X

Army Occupation of Japan9/3/454/27/52XXXXX

China Service7/7/379/7/39---X---X---

China Service Medal (Extended)9/2/454/1/57---X------

Korean Service6/27/507/27/54XXXXX

Navy Occupation of Trieste5/9/4510/25/54---X---XX

Navy Occupation of Austria5/8/4510/25/55---X------

Navy Occupation of Berlin5/8/4510/2/90---X---X---

Navy Units of the Sixth Fleet5/9/4510/25/55---X------

SW Asia Service Medal (Desert Shield/Storm)8/2/9011/2/95XXXXX

Berlin8/14/616/1/63XXXXX

Bosnia and Herzegovina (Joint Endeavor)11/20/9512/20/96XXXXX

Bosnia and Herzegovina (Joint Guard)12/20/96PresentXXXXX

Cambodia3/29/738/15/73XXXXX

Cambodia Evacuation (Eagle Pull)4/11/754/13/75XXXXX

Congo7/14/609/1/62XXXXX

Congo11/23/6411/27/64XXXXX

Cuba10/24/626/1/63XXXXX

Dominican Republic4/28/659/21/66XXXXX

El Salvador1/1/812/1/92XXXXX

Grenada (Urgent Fury)10/23/8311/21/83XXXXX

Haiti (Uphold Democracy)9/16/943/31/95XXXXX

Iraq (Northern Watch)1/1/97PresentXXXXX

Korea10/1/666/30/74XXXXX

Laos4/19/6110/7/62XXXXX

Lebanon7/1/5811/1/58XXXXX

Lebanon6/1/8312/1/87XXXXX

Libyan Area (Eldorado Canyon)4/12/864/17/86XXXXX

Mayaquez Operation5/15/755/15/75XXXXX

Panama (Just Cause)12/20/891/31/90XXXXX

Persian Gulf (Earnest Will)7/24/878/1/90XXXXX

Persian Gulf8/2/901/2/92XXXXX

Persian Gulf (Southern Watch) or Interception Operation12/1/95PresentXXXXX

Persian Gulf (Vigilant Sentinel)12/1/952/15/97XXXXX

Quemoy and Matsu Islands8/23/586/1/63XXXXX

Somalia (Restore Hope)12/5/923/31/95XXXXX

Taiwan Straits8/23/581/1/59XXXXX

Thailand5/16/628/10/62XXXXX

Vietnam and Thailand7/1/587/3/65XXXXX

Vietnam Evacuation4/29/754/30/75XXXXX

Cuba1/3/6110/23/62---X---X---

Indian Ocean/Iran11/21/7910/20/81---X---X---

Iranian/Yemen/Indian Ocean12/8/786/6/79---X---X---

Lebanon8/20/825/31/83---X---X---

Liberia (Sharp Edge)8/5/902/21/91---X---X---

Libyan Area1/20/866/27/86---X---X---

Panama4/1/8012/19/86---X---X---

Panama2/1/906/13/90---X---X---

Persian Gulf2/1/877/23/87---X---X---

Rwanda (Distant Runner)4/7/944/18/94---X---X---

Thailand5/16/628/10/62---X---X---