Fillable APPLICATION FOR A TEACHING POSITION (Bowie State University)

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APPLICATION FOR A TEACHING POSITION (Bowie State University)

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14000 Jericho Park Road
Bowie, MD 20715
Bowie State University
Office of Human Resources
C. Robinson Hall
Phone: (301) 860-3450
Fax: (301) 860-3453
APPLICATION FOR A TEACHING POSITION
IMPORTANT: Please furnish all the information requested below. Answer all questions on this form fully and accurately. If an item
does not apply to you, or if there is no information to be given, please write NOT APPLICABLE or NA.
PLEASE TYPE, OR WRITE LEGIBLY, OR PRINT CLEARLY
PART A: PERSONAL
Teaching Field Applied For:
Name:
Present Address:
Telephone:
Permanent Address:
(If different from above)
Current Position and Rank:
Current Salary:
Proposed Salary:
Name, address and phone number of persons to notify in case of emergency:
Would you accept a temporary appointment, such as one semester? YES______ NO________
14000 Jericho Park Road
Bowie, MD 20715
PART B: ACADEMIC AND PROFESSIONAL
EDUCATION
NAME AND LOCATION
OF SCHOOL
DATES
FROM - TO
Major
Type of Degree
Title of Master’s Thesis:_____________________________________________________
Advisor:__________________________________________________________________
Title of Doctoral Dissertation:_________________________________________________
Advisor:__________________________________________________________________
If doctorate has not been awarded, give time spent and number of credits received beyond the master’s degree. If you expect to
receive the doctorate shortly, give the approximate date.
List titles of publications, giving journal or magazine publishers, dates and recognition. If performing artist, cite exhibitions
and/or performances. Use additional sheets, if necessary: label Part B-5.
List honors, awards and distinctions that you have received. Cite dates.
List affiliation with professional and educational societies and offices held (including dates). Exclude organization, the name of
character of which indicates the race, creed, color or national origin of its members. DO NOT USE ACRONYMS.
Have you ever been expelled or suspended from and educational institution? YES_____________ NO________. If yes, please
explain.
APPLICANT’S AGREEMENT AND CERTIFICATION
I certify that the information given by me in this application is true in all respects, and I agree that if I am employed and it is found to be false in any
way, that I may be subject to dismissal. I authorize the use of information in this application to enable Bowie State University to verify my
statements, and I authorize the past employers, all references, and other persons to answer all questions asked by the University concerning my
ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having
furnished such information
DATE:___________________ SIGNATURE:_____________________________
Please Note:
The information you give will be used to evaluate your qualifications and experience. You may enclose your vitae, if available, with
the application. After notification of your appointment, you must request the schools attended to send an official transcripts of your
record to the Provost and Vice President for Academic Affairs, Bowie State University, Bowie, MD 20715. If you have filed a
Teacher Placement form with a graduate school, please have that institution send the form as quickly as possible to the Provost and
Vice President of Academic Affairs.
Bowie State University is an equal opportunity/affirmative action employer. The University administers its programs,
practices and procedures without regard to race, color, ancestry or national origin, disability, religion, age, sex (including
pregnancy), marital status, sexual orientation, genetic information, gender identity/expression, covered veteran status or any
other basis protected by federal or Maryland state law, as well as the University’s non-discrimination policy.
BOWIE STATE UNIVERSITY
Affirmative Action Program
CONFIDENTIAL VOLUNTARY APPLICANT DATA FORM
Last Name
First Name
Gender
Male Female
Position Applying For:
TO THE APPLICANT: This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance
Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors
to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active
duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:
A “disabled veteran” is one of the following:
A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of
military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
A person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s
discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground,
naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the
laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground,
naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded
pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act.
In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be
reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service.
For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-
USA-DOL.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box
below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the
outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE
I AM NOT A PROTECTED VETERAN
RACE/ETHNIC IDENTIFICATION – PLEASE CHECK ALL THAT APPLY
Hispanic or Latino (A person of Cuban, Mexican, Puerto
Rican, South or Central American, or other Spanish culture or
origin, regardless of race.)
Native Hawaiian or other Pacific Islander (A person having
origins in the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islands.)
American Indian or Alaska Native (A person having origins in
any of the original peoples of North or South America,
including Central America, and who maintains tribal affiliations or
community attachment.)
Black or African American (A person having origins in any of the
black racial groups of Africa.)
Asian (A person having origin in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam.)
White/Caucasian (A person having origins in any of the original
peoples of Europe, the Middle East, or North Africa.)
How did you hear about this vacancy:
Newspapers/Chronicle of Higher Education
Other State Agency (please specify):
Website (please specify):
BSU Office of Human Resources
Maryland Workforce Exchange
Other (please specify):
EEO-1 Job Category (to be completed by the EEO/AA Officer): ______________
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires ________
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities.
i
To help us measure how well we are doing, we are asking you to tell us if
you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will
choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time, we are required to ask all of our employees to update their information every five
years. You may voluntarily self-identify as having a disability on this form without fear of any punishment
because you did not identify as having a disability earlier.
How do I know if I have a disabilit
y?
You are considered to have a disability if you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such an impairment or medical
condition.
Disabilities include, but are not limited to:
• Blindness
• Autism
• Bipolar disorder
• Post-traumatic stress disorder (PTSD)
• Deafness
• Cerebral palsy
• Major depression
• Obsessive compulsive disorder
• Cancer
• HIV/AIDS
• Multiple sclerosis (MS)
• Impairments requiring the use of a wheelchair
• Diabetes
• Epilepsy
• Schizophrenia
• Muscular
• Missing limbs or
partially missing limbs
• Intellectual disability (previously called mental
retardation)
dystrophy
Please check one of the boxes below:
______________________________ ____________________
Your Name Today’s Date
YES, I HAVE A DISABILITY (or previously had a disability)
N
O, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires _
_______
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples
of reasonable accommodation include making a change to the application process or work procedures,
providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract
Compliance Programs (OFCCP) website at
www.dol.gov/ofccp.
P
UBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond
to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5
minutes to complete.
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APPLICATION FOR A TEACHING POSITION (Bowie State University)

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Completed 18 August 2020

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