This Application Must Be Filled out Completely, Typed Or Printed in Blue Or Black Ink

Classified and Hourly Pierce College District Positions HUMAN RESOURCES Application for Employment 9401 Farwest Drive SW. Email: [email protected] Lakewood, WA 98498-1999 Telephone: (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: Shifts: Full-time Part-time Hourly 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: E-mail Address: Telephone: ( )

Are you currently a permanent classified employee of a state agency Can you provide proof of United States citizenship or authorization to or public higher education institution in Washington? Yes work in the United States? Yes No No

EDUCATION Have you graduated from high school or received a GED certificate? Yes No To Total Credits From Degree, Diploma or Major or Subject College or University City, State Mo/Y Earned Mo/Yr Certificate Taken r Sem

Qtr EDUCATION Have you graduated from high school or received a GED certificate? Yes No Sem

Technical, trade, To Total Credits From Degree, Diploma or Major or Subject business or other City, State Mo/Y Earned Mo/Yr Certificate Taken school r Sem

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: ( ) Dates of Employment: From: (mo/yr) To: (mo/yr)

E-mail: Reason(s) for Leaving Salary: Hours per week:

Employer: Job Title:

City/State/Zip:

Immediate Supervisor:

Telephone: ( ) Dates of Employment: From: (mo/yr) To: (mo/yr)

Employer: Job Title:

City/State/Zip :

Immediate Supervisor:

Telephone: ( ) Dates of Employment: From: (mo/yr) To: (mo/yr)

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. 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 Vietnam-Era Veteran 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 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 Veteran within the last year from the date of this application.

Revised 7/25/2007 CAMPAIGN/EXPEDITION DATES ORGANIZATIONS PARTICIPATING Start End Army Navy Air Force Marine Corp Coast Guard Campaign or Service Medals American Defense Service 9/8/39 12/7/41 X X --- X X Army Occupation of Austria 5/9/45 7/27/55 X --- X ------Army Occupation of Berlin 5/9/45 10/2/90 X X X X X Army Occupation of Germany 5/9/45 5/5/55 X X X --- X Army Occupation of Japan 9/3/45 4/27/52 X X X X X China Service 7/7/37 9/7/39 --- X --- X --- China Service Medal (Extended) 9/2/45 4/1/57 --- X ------Korean Service 6/27/50 7/27/54 X X X X X Navy Occupation of Trieste 5/9/45 10/25/54 --- X --- X X Navy Occupation of Austria 5/8/45 10/25/55 --- X ------Navy Occupation of Berlin 5/8/45 10/2/90 --- X --- X --- Navy Units of the Sixth Fleet 5/9/45 10/25/55 --- X ------SW Asia Service Medal (Desert Shield/Storm) 8/2/90 11/2/95 X X X X X Berlin 8/14/61 6/1/63 X X X X X Bosnia and Herzegovina (Joint Endeavor) 11/20/95 12/20/96 X X X X X Bosnia and Herzegovina (Joint Guard) 12/20/96 Present X X X X X Cambodia 3/29/73 8/15/73 X X X X X Cambodia Evacuation (Eagle Pull) 4/11/75 4/13/75 X X X X X Congo 7/14/60 9/1/62 X X X X X Congo 11/23/64 11/27/64 X X X X X Cuba 10/24/62 6/1/63 X X X X X Dominican Republic 4/28/65 9/21/66 X X X X X El Salvador 1/1/81 2/1/92 X X X X X Grenada (Urgent Fury) 10/23/83 11/21/83 X X X X X Haiti (Uphold Democracy) 9/16/94 3/31/95 X X X X X Iraq (Northern Watch) 1/1/97 Present X X X X X Korea 10/1/66 6/30/74 X X X X X Laos 4/19/61 10/7/62 X X X X X Lebanon 7/1/58 11/1/58 X X X X X Lebanon 6/1/83 12/1/87 X X X X X Libyan Area (Eldorado Canyon) 4/12/86 4/17/86 X X X X X Mayaquez Operation 5/15/75 5/15/75 X X X X X Panama (Just Cause) 12/20/89 1/31/90 X X X X X Persian Gulf (Earnest Will) 7/24/87 8/1/90 X X X X X Persian Gulf 8/2/90 1/2/92 X X X X X Persian Gulf (Southern Watch) or Interception Operation 12/1/95 Present X X X X X Persian Gulf (Vigilant Sentinel) 12/1/95 2/15/97 X X X X X Quemoy and Matsu Islands 8/23/58 6/1/63 X X X X X Somalia (Restore Hope) 12/5/92 3/31/95 X X X X X Taiwan Straits 8/23/58 1/1/59 X X X X X Thailand 5/16/62 8/10/62 X X X X X Vietnam and Thailand 7/1/58 7/3/65 X X X X X Vietnam Evacuation 4/29/75 4/30/75 X X X X X Cuba 1/3/61 10/23/62 --- X --- X --- Indian Ocean/Iran 11/21/79 10/20/81 --- X --- X --- Iranian/Yemen/Indian Ocean 12/8/78 6/6/79 --- X --- X --- Lebanon 8/20/82 5/31/83 --- X --- X --- Liberia (Sharp Edge) 8/5/90 2/21/91 --- X --- X --- Libyan Area 1/20/86 6/27/86 --- X --- X --- Panama 4/1/80 12/19/86 --- X --- X --- Panama 2/1/90 6/13/90 --- X --- X --- Persian Gulf 2/1/87 7/23/87 --- X --- X --- Rwanda (Distant Runner) 4/7/94 4/18/94 --- X --- X --- Thailand 5/16/62 8/10/62 --- X --- X ---