I. PERSONAL DATA
NAME:
LAST FIRST MIDDLE INITIAL
(Legal Name)
LAST FOUR DIGITS OF
SOCIAL SECURITY NUMBER
MAILING ADDRESS:
NUMBER AND STREET CITY STATE ZIP
TELEPHONE:
HOME: ALTERNATE:
E-mail:
Are you legally entitled to work in the United States? Yes No
Proof of your identity and employment eligibility must be provided within three (3) business days from date of hire as required by the Immigration Reform and Control Act of 1986.
Are you a current RSC employee? Yes* No
Have you previously worked for RSC? Yes* No
*If yes, Where:
When:
Are you known by another name? Yes* No
*If yes, list other name(s):
List names and relationship of relatives working for RSC.
EMPLOYMENT DESIRED: Part-Time Adjunct Full-Time
If applying for Part-Time or Adjunct employment, list area(s)/position(s) of interest:
FULL-TIME POSITIONS:
1. Job Title:
2. Job Title:
3. Job Title:
Have you ever been convicted or received a deferred sentence for any offense other than minor traffic violations? Yes* No
*If yes, provide date and explanation on Applicant Information Profile form. A conviction will not necessarily result in denial of employment.
II. EDUCATION AND OCCUPATIONAL TRAINING*
Please list all formal education/training including any current enrollment.
*Unofficial degree conferring transcripts to be submitted with Application for Employment.
Name & Address of Institution
Dates Attended
(Mo/Yr)
Fields of Study or
Titles of Special Courses
Hours Completed
Diploma, Degree
or Certificate
From
To
High School
Vo-Tech or Business School
College or University
Other
Software Skills:
List current valid professional or trade licenses/certificates, registrations or permits:
APPLICATION FOR EMPLOYMENT
Please print in ink or type. Incomplete applications will NOT be processed.
RETURN TO:
Human Resources/AAO
Rose State College
6420 Southeast Fifteenth Street
Midwest City, OK 73110-2799
ROSE STATE COLLEGE
An Equal Opportunity/Affirmative Action Employer
Telephone: (405) 733-7979
http://www.rose.edu/human-resourcesIII. PHILOSOPHY STATEMENT
To be completed by applicants for Teaching and/or Administrative/Professional positions.
Please state your philosophy of education, especially as it relates to the two-year college.
IV. PROFESSIONAL DEVELOPMENT
To be completed by applicants for Teaching and/or Administrative/Professional positions.
Thesis and/or dissertation title(s):
Article(s), paper(s), and book(s) published:
Professional organization(s), professional memberships, honors, community service/activities:V. EMPLOYMENT HISTORY*
Please list employment for the last ten (10) years, starting with the most recent first. *A resume may be attached in addition to completing this section.
1. Name of Employer
Type of Business
Part-Time Full-Time
Address Street City State ZIP
Phone
Dates Employed (Mo/Yr)
From: To:
Starting Title & Salary
Final Title & Salary
May we contact now?
Yes No
Name of Supervisor/Title
Reason for Leaving
Brief Description of Duties 2. Name of Employer
Type of Business
Part-Time Full-Time
Address Street City State ZIP
Phone
Dates Employed (Mo/Yr)
From: To:
Starting Title & Salary
Final Title & Salary
May we contact now?
Yes No
Name of Supervisor/Title
Reason for Leaving
Brief Description of Duties
3. Name of Employer
Type of Business
Part-Time Full-Time
Address Street City State ZIP
Phone
Dates Employed (Mo/Yr)
From: To:
Starting Title & Salary
Final Title & Salary
May we contact now?
Yes No
Name of Supervisor/Title
Reason for Leaving
Brief Description of Duties
4. Name of Employer
Type of Business
Part-Time Full-Time
Address Street City State ZIP
Phone
Dates Employed (Mo/Yr)
From: To:
Starting Title & Salary
Final Title & Salary
May we contact now? Yes No
Name of Supervisor/Title
Reason for Leaving
Brief Description of Duties
5. Name of Employer
Type of Business
Part-Time Full-Time
Address Street City State ZIP
Phone
Dates Employed (Mo/Yr)
From: To:
Starting Title & Salary
Final Title & Salary
May we contact now?
Yes No
Name of Supervisor/Title
Reason for Leaving
Brief Description of DutiesVI. REFERENCES
Please list three business/work* references that are not related to you and are not previous supervisors.
*If not applicable, list three school or personal references that are not related to you.
1. Name
Business Name and/or Relationship to Applicant
Phone
Years Known
2. Name
Business Name and/or Relationship to Applicant
Phone
Years Known
3. Name
Business Name and/or Relationship to Applicant
Phone
Years Known
VII. CERTIFICATION
Please read the following statement before signing and dating this Application for Employment.
I certify that the above information is correct and complete to the best of my knowledge and belief. I authorize and permit Rose State College to verify all information provided herein, and waive privacy rights, if permitted by law, when such waiver is required to verify my job-related knowledge, skills, and abilities including physical ability, police record, and eligibility to work. I understand that willful falsification or misrepresentation is sufficient reason for terminating any consideration of me for employment and for dismissal from employment. If employed, I agree to comply with the employment policies, rules, and regulations of this employer provided such compliance does not contravene those rights and privileges afforded me by law, regulation, or policy.
Signature of Applicant Date
Equal Employment Opportunity Statement
Rose State College, in compliance with Titles VI and VII of the Civil Rights Act of 1964, as amended; Executive Order 11246, as amended; Title IX of the Education Amendments of 1972; Americans with Disabilities Act of 1990, as amended by the ADA Amendments Act of 2008 (ADAAA); Genetic Information Nondiscrimination Act of 2008 (GINA); and other federal laws and regulations, does not discriminate on the basis of race, color, sex, age, national origin, religion, disability, genetic information, sexual orientation, or status as a veteran in any of its policies, practices, or procedures. This includes but is not limited to: admissions, employment, financial aid, and educational programs, activities or services. The Affirmative Action Officer is the Executive Director, Human Resources/AAO. Issues of noncompliance need to be referred to the Affirmative Action Officer, Administration Building, Room 104, telephone (405) 733-7979.
RESUMES WILL NOT BE ACCEPTED IN LIEU OF COMPLETED APPLICATION FOR EMPLOYMENT.
APPLICANT IS RESPONISBLE FOR CONTACTING HUMAN RESOURCES TO REQUEST CONSIDERATION FOR CURRENT OPENINGS.
APPLICATIONS WILL REMAIN ACTIVE FOR A PERIOD OF ONE (1) YEAR FROM DATE RECEIVED BY HUMAN RESOURCES.
RETURN ORIGINAL SIGNED APPLICATION FOR EMPLOYMENT AND UNOFFICIAL DEGREE
CONFERRING TRANSCRIPTS TO HUMAN RESOURCES.
HUMAN RESOURCES OFFICE USE ONLY – APPLICANTS DO NOT FILL OUT THIS SECTION
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UPDATED 09/12ROSE STATE COLLEGE
APPLICANT INFORMATION PROFILE
The College, as an Equal Opportunity/Affirmative Action Employer, is required to maintain statistics on the race and sex of all applicants. This information is used to complete the necessary reports and to monitor the College’s success with its Affirmative Action Plan.
This information is requested on a voluntary basis and will be kept confidential. The information will not be used to discriminate against or to show preference for any applicant in the hiring process.
NAME:
SSN:
(Last) (First) (Middle)
MAILING ADDRESS:
TELEPHONE:
(Street) (City) (State and ZIP)
Ethnic Group/Race:
American Indian or Alaskan Native Asian
Hispanic Native Hawaiian or Pacific Islander
White Other _____
Black or African American
Date of Birth / /
Sex Male Female
Veteran Yes No
Vietnam Era Yes No
How did you find out about the College?
College Employee Publication
State Employment Agency Billboards
Friend Walk-In
Internet/College Home Page HigherEdJobs
Other
Comments:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Rose State College, in compliance with Titles VI and VII of the Civil Rights Act of 1964, as amended; Executive Order 11246, as amended; Title IX of the Education Amendments of 1972; Americans with Disabilities Act of 1990, as amended by the ADA Amendments Act of 2008 (ADAAA); Genetic Information Nondiscrimination Act of 2008 (GINA); and other federal laws and regulations, does not discriminate on the basis of race, color, sex, age, national origin, religion, disability, genetic information, sexual orientation, or status as a veteran in any of its policies, practices, or procedures. This includes but is not limited to: admissions, employment, financial aid, and educational programs, activities or services. The Affirmative Action Officer is the Executive Director, Human Resources/AAO. Issues of noncompliance need to be referred to the Affirmative Action Officer, Administration Building, Room 104, telephone (405) 733-7979.REQUEST FOR AMERICANS WITH DISABILITIES
If you do not require any accommodations at this time, please acknowledge by signing and dating this form.
If you are an individual with a disability and accommodations are needed, please describe the accommodation(s) required in the space below.
Please sign and date this form.
Signature of Applicant Date _______
