Fort Lewis College s2

FORT LEWIS COLLEGE Durango, CO 81301

Employment Application & Certification Form (Required for Employment)

Fort Lewis College does not discriminate on the basis of race, color, religion, national origin, gender, age, disability, veteran status (disabled or Vietnam Era) sexual orientation, political affiliation or any other status protected by law or regulation. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job-related factors.

Answer each section fully and accurately and attach an up-to-date resume/CV. No action can be taken on this application until you have completed all areas and questions. Use blank paper if you do not have enough room on this application form. PLEASE PRINT OR TYPE, except for your signature. Position for which application is submitted:

Social Security #: Today’s Date:

GENERAL INFORMATION Last Name: First Name: Middle Name:

Address: City and State: Zip Code:

Home Telephone: Mobile/Cell Phone: Office Phone:

Are you a citizen of the United States? Yes No If no, what is your residency/visa status? If hired, can you furnish proof that you are eligible to work in the United States? Yes No Have you ever been convicted* of any crime(s) and/or are any charges pending against you (other than minor traffic violations or juvenile offenses)? Yes No *A conviction includes a plea of guilty, nolo contendere or Alford, or finding a verdict of guilt, regardless of whether judgment or sentence was imposed. If yes, please attach a separate page listing the nature of the conviction(s), date(s) of occurrence and state(s) in which it/they occurred. A conviction does not automatically disqualify you from consideration, so please be candid. EDUCATION Check if attached resume/CV contains all requested information listed below. If not, please complete: Name of Institution: Full Address:

Dates of Attendance: Degree and Year:

Name of Institution: Full Address:

PUBLICATIONS AND/OR PROFESSIONAL ACTIVITIES Check if included on attached resume/CV. If not, please list:

WORK EXPERIENCE Check if attached resume/CV contains all requested information listed below. Please account for at least the last 10 years of employment, including any periods of non-employment. Attach additional pages, if needed. If resume/CV does not include all information listed below, please complete: Name of Employer: Full Address and Phone Number:

Position Held: Dates Employed: Supervisor’s Name:

Responsibilities:

Name of Employer: Full Address and Phone Number:

Responsibilities:

HONORS/AWARDS Check if included on attached resume/CV. If not, please list:

CERTIFICATION, CONSENT AND RELEASE (Please read each statement carefully before signing.)

I certify that all information provided in this employment application and any resume/CV attached hereto is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all information contained in this application or in any attached resume/CV. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that this application, verbal statements by the Colleges’s administration or staff, or subsequent employment does not create an express or implied contract of employment or any guarantee of employment for any definite period of time. Only the Board of Trustees for Fort Lewis College has that authority to enter into an agreement of employment for any specified period and such agreement must be in writing, signed on behalf of the Board and by the employee. If employed, I understand that I have been hired at the will of the Board of Trustees for Fort Lewis College and my employment may be terminated at any time, with or without reason and with or without notice, unless expressly provided otherwise by Board resolution or policy. (Teaching Faculty positions are subject to the Fort Lewis College’s Faculty Handbook personnel policies and procedures.)

I have read, understand and by my signature consent to these statements.

______Signature Date

State of Colorado Faculty Oath or Affirmation State law requires that each member of our faculty sign and attest to the enclosed oath or affirmation as a condition of their employment by the College. Listed below is a copy of the applicable Colorado statute for your review. The statute, in its current form, was enacted in 1969 and has been upheld by the courts.

West’s Colorado Revised Statutes Annotated Title 22. Education Teachers Article 61. Teacher Employment

→§ 22-61-104. Professors, instructors, and teachers in state institutions of higher education to take oath or affirmation

(1) Every person employed to teach in any state university, college, junior college, community college, or technical college in the state of Colorado, before entering upon or continuing the discharge of his duties, shall take the following oath or affirmation; except that no person employed to teach in a temporary capacity who is a citizen of a nation other than the United States shall be required to take such oath or affirmation:

“I solemnly (swear) (affirm) that I will uphold the constitution of the United States and the constitution of the state of Colorado, and I will faithfully perform the duties of the position upon which I am about to enter.”

(2) The said oath or affirmation shall be administered by any person authorized to administer oaths in the state of Colorado. STATE OF COLORADO

______County

I solemnly (swear) (affirm) that I will uphold the constitution of the United States and the constitution of the state of Colorado, and I will faithfully perform the duties of the position upon which I am about to enter.

______Faculty Member’s Signature

______Print Faculty Member’s Name

Subscribed and (sworn) (affirmed) before me this ______day of ______20____.

My Commission expires:______.

______Notary Public

Address:______

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