Merced College Office of Human Resources Position Title  3600 “M” Street Merced, CA 95348-2898 Today’s Date  Phone: (209) 381-6479 Fax: (209) 384-6103 E–Mail: [email protected] Received by HR  WEB: http://www.mccd.edu/offices/hr/jobs/classified.html Application for Classified Employment

Instructions and Information 1. Applications are accepted only for positions that are 5. Fill out application entirely. Do not mark “See Resume.” currently open. 6. Incomplete or illegible applications will not be considered. A 2. All application materials (refer to job announcement) must separate application is required for each position; copies are be received in the Human Resource Office by 4:30 p.m. on acceptable. the final filing date. 7. Applications meeting minimum qualifications will be 3. Any application, resume or other materials submitted for screened to determine which individuals will be called for an employment will become the property of the District and will interview. not be returned to the applicant. 8. Allow a minimum of two weeks after the closing date to be 4. Please type or print with black or blue ink or download the contacted about your application status. file from our WEB site and use WORD to complete the 9. Contact us to request special accommodation if needed. application blank. Tab to each field. 10. Sign and date your application. Alias(es)/Other Name:  Names Last First Middle Address:  – City State Zip Telephone Number (Day) Cell Number: ( ) – ( ) – E–Mail Address Education High School Technical School College Graduate Check highest level 1= 2= 3– 4= 1= 2= 3– 4= 1= 2= 3– 4= 1= 2= 3– 4= completed:  Degree Earned Name of Educational Institution, City and State (most recent first) Major/Minor/Concentration Certificate

Skills/Abilities (Please refer to qualifications section(s) of job announcement.) List languages other than English you can:  Speak:  Read:  Write:  Keyboarding Speed:  Cwpm Dictation/Transcription: Wpm Driver’s License number and class:  Expiration Date:  Equipment / Machinery:  List software programs you can use proficiently:  Word Processing:  Spreadsheet:  Database:  Internet:  Operating System:  Other: 

Page 1 of 5 Employment Record: List your present or most recent employer first. Include any U.S. Armed Forces experience. Account for employment during the past ten years. You may include volunteer experience (you may exclude the names of organizations that may reveal your race, color, religion, national origin, veteran status, ancestry, sex, sexual orientation, age, or physical disability). If more space is required, attach additional sheets using the same format. Reference checks will be conducted.

Employer Type of Business: Start Date: End Date:

Address: Hours worked per week: Starting Salary: Ending Salary:

City, State, Zip Job Title: Number of people you directly supervised:

Supervisor’s Name and Title: Telephone Number: Reason for leaving: ( ) – Description of Job Duties Employer Type of Business: Start Date: End Date:

Address: Hours worked per week: Starting Salary: Ending Salary:

City, State, Zip Job Title: Number of people you directly supervised:

Supervisor’s Name and Title: Telephone Number: Reason for leaving: ( ) – Description of Job Duties Employer Type of Business: Start Date: End Date:

Address: Hours worked per week: Starting Salary: Ending Salary:

City, State, Zip Job Title: Number of people you directly supervised:

Supervisor’s Name and Title: Telephone Number: Reason for leaving: ( ) – Description of Job Duties Employer Type of Business: Start Date: End Date:

Address: Hours worked per week: Starting Salary: Ending Salary:

City, State, Zip Job Title: Number of people you directly supervised:

Supervisor’s Name and Title: Telephone Number: Reason for leaving: ( ) – Description of Job Duties

Page 2 of 5 During the selection process, we may conduct reference checks with employers, supervisors, and references. If you do not want a certain employer or supervisor contacted initially indicate who and why:

Note: Final selection consideration may be contingent upon comprehensive employment and reference checks, including any exclusion above. References Name:  Position:  Relationship:  Telephone:  ( ) – Address:  City / State / Zip  , – Name:  Position:  Relationship:  Telephone:  ( ) – Address:  City / State / Zip  , – Name:  Position:  Relationship:  Telephone:  ( ) – Address:  City / State / Zip  , – General Information  Are you able, upon employment, to submit verification that you are a United States citizen or are eligible to work in the United States? The Immigration Reform and = Yes = No Control Act of 1986 requires Merced College to obtain original documentation from every employee which verifies identity and authorizes employment in the U.S.  Have you ever been convicted of any crime? If “yes”, please state on the following = Yes = No page*for each conviction the specific charge for which you were convicted, the date and place of conviction, as well as the jail/prison sentence or fine you received. Please be aware that certain offenses need not be reported: (1) Any conviction for which the record has been judicially ordered sealed, expunged, or statutorily eradicated (e.g. sealed juvenile offense records); (2) Any misdemeanor conviction for which probation has been successfully completed and the case judicially dismissed, pursuant to Penal Code 1203.4. Despite these restrictions, any conviction for certain sex and drug-related offenses specified in Education Code Sections 87010 and 87011 must be reported regardless of whether the case was judicially dismissed, pursuant to Penal Code Section 1203.4. A record of conviction will not necessarily constitute an automatic bar to employment.  Have you ever been dismissed from employment or resigned in lieu of being dismissed = Yes = No for inefficiency, delinquency or misconduct? If “yes” explain on the following page.* A “yes” answer will not automatically preclude you from employment consideration.  Merced College is hereby authorized to contact my present employer. = Yes = No  Merced College is hereby authorized to contact my past employers. = Yes = No  Merced College is hereby authorized to contact other references. Any exceptions are = Yes = No noted above. Page 3 of 5  If you are under 18 years old, can you submit a work permit upon hire? = Yes = No  Does Merced College employ a relative of yours? If “yes” give name and relationship = Yes = No below.* *Remarks/explanations: Certification and Agreement of Applicant I certify that the information I have provided in applying for this job is true and complete to the best of my knowledge and belief. I give Merced Community College District and its authorized agents permission to verify and/or disclose any information given in connection with this application for personnel/employment purposes. I acknowledge that any misstatements or omissions in these application materials may be cause for elimination from further consideration or dismissal if hired. I hereby authorize any and all persons and agencies to furnish to Merced Community College District any information, including documents in my personnel file, which may be necessary to verify this application and any other materials submitted and hereby waive any rights of privacy to the information or documents which I may have under any federal, state or local law, ordinance or rule. I also understand that an incomplete application may delay or prevent employment opportunities with Merced College. I hereby release Merced Community College District, as well as those contacted by the college, from any liability or damage which may result from furnishing or using the information requested. Applicant’s Signature: 

Date: 

Merced Community College District is an Equal Opportunity Employer

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Page 4 of 5 Merced College/Demographic Survey (Confidential) As an equal opportunity employer, we are required to compile summary data on applicants for employment. We are requesting your assistance in providing the information below. Please return this form with your application. The completion of this questionnaire is voluntary on your part. The form will be kept confidential and separate from all hiring documents and will not be forwarded to the colleges/departments making employment decisions. Name: Date: Social Security Number: – – Position applied for: Full–time Part–time

Personal: Male Female Over 40 years of age? Yes No Are you a person with a disability? *As defined in the Americans with Disabilities Yes No Act of 1990, a disabled person is one who: If yes, do you need any accommodation(s)? Yes (1) Has a physical or mental impairment which No substantially limits one or more major life If yes, please contact the College where you are applying for activities; services. Individual phone numbers are provided on Page 1 of (2) Has a record of such an impairment; or this application. (3) Is regarded as having such impairment. □ African-American, Non-Hispanic B □ Hispanic/Latino HIS

Heritage: □ American Indian/Alaskan N □ Japanese AJ □ Asian Indian AI □ Korean AK □ Asian Other AX □ Laotian AL □ Cambodian AM □ Mexican-American, Chicano HM □ Central American HR □ Non-Hispanic/Latino NHS □ Chinese AC □ Pacific Islander Other PX □ Filipino F □ Samoan PS □ Guamanian PG □ South American HS □ Hawaiian PH □ Vietnamese AV □ Hispanic Other HX □ White, Non-Hispanic W Recruitment Information: How did you hear about this position/job? Chronicle of Higher Education Chancellor’s Registry District flyer District Telephone Job Line Friend Graduate department Referral Word of Mouth Walk in to HR/Personnel Office of College Internet (please specify URL) Job Fair (please identify location) Journal or other

discipline publication (please identify) Local Publication(s) (please identify) Other (please indicate source)...... We appreciate your assistance in providing statistics to help us improve our recruitment efforts.

MC Form-993A

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