Alabama Community College System Application No. APPLICATION FOR EMPLOYMENT Northwest-Shoals Community College n o i t

i Title of position for which you are applying: s Date of o

P Application n o i t a m r o f n I l

a Last Name First Name Middle Initial n o s r e

P Address City State Zip n o i t a m

r Contact Information o f Phone: Home Work Cell E-mail Address n I y r School/College Dates Major Minor Degree(s) a d

d Attended Earned n n o

a From / To c e High S r School/ a n d o GED i n t o a c c e u College s d t E s o y P College

College

Other (Specify) l a n

o Are you currently employed or have you been employed within the last twelve months at an Alabama i t i Community College System college? d

d Yes No A n o

i If yes, list the name of the college(s):______t a m r o f n I t

n Please list most recent employment experience first. e y

r Employer Telephone Number Job Duties m o y t o s l i p H m Address Dates of Employment E

Title Full-time Part-time Hourly Rate/Salary Reason for Leaving May wecurrent contact your employer?

Skills, Awards, Employment Employment Employment Employment Professional (Continued) (Continued) (Continued) (Continued) Certificates or History History History History ReasonLeaving for Title Address Employer ReasonLeaving for Title Address Employer ReasonLeaving for Title Address Employer ReasonLeaving for Title Address Employer     Full-time Full-time Full-time Full-time     Part-time Part-time Part-time Part-time  Yes Dates of Datesof Employment Datesof Employment Dates of Datesof Employment Datesof Employment TelephoneNumber TelephoneNumber TelephoneNumber TelephoneNumber Hourly Rate/SalaryHourly Rate/SalaryHourly Hourly Rate/SalaryHourly Rate/SalaryHourly  No JobDuties JobDuties JobDuties JobDuties Activities subjected to discrimination under any program, activity, or employment. (Each institution will make reasonable accommodations for accommodations reasonable make will institution (Each employment. or activity, program, oremployees.) disabled applicants qualified any under discrimination to subjected sex, disability, status, marital orbe denied thebenefitsof, from participation in,be statelaw,shall beexcluded as defined by federal and oranyotherprotectedclass age, religion, origin, national color, race, limitation, without including, characteristic or criterion impermissible any of basis the on promotion, or employment for applicant or employee no that Trustees, of Board System College Community Alabama the of control the under colleges technical and community postsecondary all including System, College Community Alabama the of policy the is It you member the Are a College Community Alabamaof Applicant System Pool?

Consent Agreement Conviction(s)Felony RelationshipFamily References and true information on this application may result indisqualificationordismissal. onthisapplicationmay result and trueinformation full provide to failure that understand I information. such furnishing for whatsoever nature any of damage for liability all and any from them release hereby to do I and application harmless, persons such this hold to agree concerning I officials. information college to pertinent information such furnish have may who persons any and further employers I former to, followed. permission procedures give be the will that checks check. found background background criminal said is of cost criminal the for turpitude responsible be concerning will I moral that understand policy involving Trustees crime of any Board or the felony for a established for conviction a event the in that investigation. history background criminal a conduct to assigns its and/or System College AlabamaCommunity the within authority employing my authorize hereby I and investigation background criminal satisfactory all truthfully and fully convictions/records. answered have criminal I that regarding warrant questions and represent I and further, experience, And education, of licensures. verification and/or documented certifications provide required must I that understand I that acknowledge further I belief. and knowledge my of best the to true and full is application this on given have I information the that warrant and represent I theft, involving crime any or felony any to guilty or Ifyes, explainbelow: contest no pled or of dishonesty,orviolence, sexualmisconduct? convicted been ever you Have Ifyes, name(s),listthe relationship, and employer/positionof relative(s): Communityor College, ofany Alabamamember the Community CollegeSystem of Board Trustees? Are you a any relative of in employee Alabama the Collegesystem, Community including Northwest-Shoals consanguinityto anyjob, position, officeor of state any profit with with its or of agencies. theFor purposes of disclosure,relative anyincludesperson related the within degree fourth ofor affinity qualifications, verifying character, work experience.or information provide can who relatives, than other references, three list Please Name and Name Title Signatureof Applicant Northwest-ShoalsCommunity College Attention Human Attention Resources Muscle Muscle Shoals, AL 35662  Yes I understand that any offer of employment is contingent upon a upon contingent is employment of offer any that understand I P.O. Box2545P.O. 256-331-5229  Yes  Address No  No  Yes I hereby expressly request, and request, expressly hereby I Date  PhoneNumber No

I understand I EQUAL EMPLOYMENT OPPORTUNITY INFORMATION (Optional Form)

The following information is gathered solely for reporting purposes and will not be used to evaluate the applicant’s qualifications, suitability, or desirability for employment.

Last Name First Name Middle Name Date of Birth

Ethnic Background (check one): Gender (check one):

Native American Male White, not of Hispanic origin Female Hispanic

African American

Asian/Pacific Islander

Multi-racial

Other

Miscellaneous Information Have you ever been YES NO employed by the College? Position From To

How did you learn of this job opening?