J.F. Drake State Community and Technical College

Rev. Per ACCS 1-12-17 ALABAMA COMMUNITY COLLEGE SYSTEM HR011217 APPLICATION FOR EMPLOYMENT J.F. DRAKE STATE COMMUNITY AND TECHNICAL COLLEGE

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

o P n Date of Application o i t a m r l o f a Last Name First Name Middle Initial n n I

o s r e P

n Address City State ZIP o i t a m r Contact Information o f n

I Phone Home Work Cell E-mail Address

d Dates Attended Degree(s) n School/College Major Minor

a From/To Earned y

r High a School/ d n GED o c e

S College n o i t a c College u d E y r

a College d n o c Other e s

t (Specify) s o P l a Are you currently employed or have you been employed within the last twelve months at an Alabama Community n o College System college? i t i d

d Yes No A n

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

o Please list most recent employment experience first t s i Job Duties H

Employer Telephone Number t n e m

y Address Dates of Employment o l p m Title Full-time Part-time Hourly Rate/Salary E Reason for Leaving Supervisor

May we contact employer:May your current Professional ActivitiesSkills, Awards, Certificates of Employment History (Continued) Attach additional page ifneeded. Attach additionalpage Reason for Leaving Address Employer Reason for Leaving Address Employer Reason for Leaving Address Employer Reason for Leaving Address Employer

Title Title Title Title

Full-time Full-time Full-time Full-time Part-time Part-ti Part-time Part-time EmploymentDates of Number Telephone Supervisor Hourly EmploymentDates of Number Telephone Supervisor Hourly EmploymentDates of Number Telephone Supervisor Hourly EmploymentDates of Number Telephone Supervisor Hourly Rate/Salary Yes Rate/Salary Rate/Salary Rate/Salary No Job Duties Job Duties Job Duties Job Duties employment. (Each institution will make reasonable accommodations for qualified disabled applicantsor employees.) for qualified will makereasonable accommodations employment. (Eachinstitution or under anyprogram, activity, be subjected todiscrimination thebenefits of,or from participation in,be denied age, be excluded or creed,nationalorigin, of race,color,disability, sex,religion, shall,onthegrounds of Education, thatnoperson Alabama StateBoard underthecontrolof allpostsecondary institutions Educationincluding Department ofPostsecondary It isthepolicyof theAlabama Return to: Return ApplicantPool? memberoftheAlabama Community College System Are you a Consent Agreement Conviction(s)Felony Relationship(s)Family References Title Name and work experience. qualifications,character,or provideinformation verifying otherthanrelatives,who can listthreereliablereferences, Please provide full and true information on this application may result in disqualification ordismissal. mayresultindisqualification information onthisapplication provide full andtrue thatfailure to suchinformation. Iunderstand whatsoever for furnishing liabilityfordamage ofany nature them fromany andall Idoherebyrelease suchpersonsharmless,and officials. Iagreetohold suchinformation to college this applicationtofurnish concerning mayhavepertinentinformation andanypersonswho givepermission to,former employers expressly request,and check. Ihereby costof saidcriminal background thatIwill beresponsiblefor the Ifurtherunderstand 623.01 will befollowed. forStateBoardPolicy setoutintheguidelines thattheprocedures moralturpitude isfound a felonyorany crimeinvolving aconvictionfor thatintheevent historyinvestigation.Iunderstand conductacriminal background System and/oritsassignsto College within theAlabamaCommunity authorize my employing authority investigationandIhereby criminal background uponasatisfactory of employment iscontingent thatany offer criminal convictions/records. Iunderstand questions regarding truthfully all thatIhaveanswered fully and Irepresentandwarrant and/orlicensures.Andfurther, required certifications experience,and verificationofeducation, thatImustprovidedocumented thatIunderstand belief. Ifurther acknowledge of my knowledge and isfullandtruetothebest givenonthisapplication thattheinformationIhave I representandwarrant below:If yes,explain misconduct? sexual or theft, dishonesty,violence, toanyfelony orany crimeinvolving orplednocontestguilty everbeenconvictedof Have you employer/position ofrelative(s) name(s), relationship,and If yes,listthe theStateBoardofEducation? College,orany member of Technical Community and System, includingJ.F.DrakeState of theAlabama Community College arelativeof anyemployee Are you anyof itsagencies. oroffice of profit with stateorwith toanyjob,position, consanguinity or fourthdegreeofaffinity personrelatedwithin the includesthefollowing: any purposesof disclosure,relative For the (256) 551-7278 (256) Alabama 35811 Huntsville, MeridianStreet, North 3421 Resources Office ofHuman Community andTechnicalCollege J.F. DrakeState Signature ofApplicant

Yes Address

Yes Yes Phone Number No Date No REQUEST, AUTHORIZATION, CONSENT, & RELEASE FOR BACKGROUND INFORMATION

I have been informed and acknowledged that on April 13, 2016, the Alabama Community College System Board of Trustees adopted Policy 623.01 requiring criminal background checks for all new and current employees.

I understand that I may voluntarily consent to the use of my social security account number for the purpose of conducting a criminal background check. I further understand that my voluntary consent to use my social security account number is being requested for purposes of conducting a criminal background check, pursuant to the authority of the Alabama Community College System Board of Trustees policy regarding criminal background checks. I understand that neither the Alabama Community College System nor any employing authority within the Alabama Community College System will deny me any right, benefit or privilege provided by law because of my refusal to voluntarily consent to the use of my social security account number for the limited purpose of conducting a criminal background check pursuant to the Alabama Community College System Board of Trustees policy regarding criminal background checks.

_____ I voluntarily consent to the use of my social security account number for the limited purpose of conducting a criminal background check. Social Security# ______

_____ I do not consent to the use of my social security account number for the limited purpose of conducting a criminal background check.

The information I have given in my employment application, interviews, and/or related resumes and documents is true, complete, and accurate.

I understand and agree that if employed, and/or during any period of employment, any false statements, misrepresentations of facts, or omission made by myself become known, my employment shall be subject to immediate termination.

I understand that in the event a conviction for a felony or any crime involving moral turpitude is found that the procedures established for the Board of Trustees policy concerning criminal background checks will be followed.

I have read and completely understand this release.

Applicant’s Signature: ______Date: ______

Applicant’s Name (Please print): ______

Applicant’s Address: ______

Applicant’s Birthday: ______

1/12/17 EQUAL EMPLOYMENT OPPORTUNITY INFORMATION

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.

Name ______Last First Middle Date of Birth

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

( ) Native American ( ) Male ( ) White, not of Hispanic origin ( ) Female ( ) Hispanic ( ) Black, not of Hispanic origin ( ) Asian/Pacific Islander ( ) Multi-racial ( ) Other MISCELLANEOUS INFORMATION

Have you ever been employed by the College? ( ) Yes ( ) No

Position: ______Employed from ______to ______

Name(s), relationship, and department of relative(s) presently employed by the College:

______

How did you hear about this job announcement?

 Newspaper advertisement (classified print ad)  Montgomery Advertiser  Birmingham News  Huntsville Times  Mobile Press-Register  Other (please specify) ______

 Website  Alabama Community College System (accs.cc)  Alabama Two-Year College (please specify) ______  Other (please specify) ______

 On-line advertisement  CareerBuilder.com  al.com  IMDiversity.com Alabama Job Link (joblink.alabama.gov)  Alabama Employment Office  Other (please specify) ______

 Alabama Community College Applicant Pool Member

 Radio

 Other (please specify) ______

1/12/17