APPLICATION FOR EMPLOYMENT FOR WORK STUDY STUDENT WORKERS
INDIAN RIVER STATE COLLEGE
www.irsc.edu
3209 Virginia Avenue, Fort Pierce, Florida 34981-5596 Telephone: 1-772-462-7280
Complete this application only if a valid 2020-2021 FASFA application is on file. If you have not filed, you must file
and complete all documents before you can be considered for Federal Work Study
. Completing this application does
not guarantee you a Federal Work Study position. This application cannot be processed for employment unless all
questions are fully and accurately answered and all information blanks completed.
PERSONAL INFORMATION
Last Name First Name Middle Initial
IRSC Student ID: Major: Anticipated Grad Date:
Other names which may appear on educational or work records:
Mailing Address
City
State
Zip Code
Residence or Street Address
City
State
Zip Code
Email Address
Cell Phone Number
Home Phone Number
Work Phone Number
POSITION INFORMATION
Position Applying For:
Preferred Campus(es):
Main Campus Fort Pierce Chastain Campus Stuart Mueller Campus Vero Beach
Dixon Hendry Campus – Okeechobee Pruitt Campus – PSL Blackburn Educational Building
Indicate days and hours available to work per week:
Semester(s) you would like to work: Fall 2020 Spring 2021 Summer 2021
Indicate if interested in being a Peer Tutor: Yes No
List the subject(s) you can tutor:
Have you completed at least 30 credit hours? Yes No
If so, do you have at least a 3.0 GPA? Yes No
If your answer is yes to both questions, would you like to be considered for a peer mentor position?
Yes No
OTHER INFORMATION
Are you legally eligible and currently in possession of legal authorization to be employed in the
United States?
Yes No
(Questions/concerns may be directed to Human Resources.)
(Proof of identity and eligibility will be required upon employment)
Do you have any relatives working for Indian River State College? Yes
No
If Yes, please list their names and relationship:
CRIMINAL HISTORY
NOTE: A conviction will not necessarily disqualify you from employment. Factors such as the
seriousness and nature of the offense, age at time of the offense, rehabilitation, and other
factors to individually assess the circumstances will also be taken into account.
If any of the answers to the questions below are a “Yes,” then disclose where convicted, dates, nature
of charge(s), pleas, fines, disposition, and explain or describe them. Please attach separate sheet.
(Application will not be processed until documents and explanation are received.)
Have you ever been convicted of a felony or misdemeanor in the 1
st
degree? Yes No
Are you currently on probation or parole or have any charges pending or are you enrolled in a pretrial
diversion or other similar program? Yes No
EDUCATIONAL INFORMATION
Schools Attended
(include current)
Location
Did you
graduate?
Academic Degree and
Major
High School
Voc-Tech/College/University
SKILLS, TRAINING AND AWARDS
List any skills (e.g., languages spoken fluently, computer skills, bookkeeping, equipment you can
operate), additional training (e.g., professional seminars, company sponsored courses), awards or honors
that you believe have a bearing on your qualifications for this position.
THE AMERICANS WITH DISABILTIES ACT AND OUR APPLICATION PROCESS
The Americans with Disabilities Act protects individuals with disabilities from employment discrimination.
Indian River State College is
committed to the principle that no one will be denied any employment
opportunity, or otherwise discriminated against in our application, interview, selection, and hiring process
simply because he/she has a disability, or a relationship with a disabled person.
All selection, hiring, and placement decisions will be based upon your education, experience, skill and
other legitimate qualifications for the job you seek.
Indian River State College will make a reasonable accommodation to any disability you may have in order
to allow you to fairly apply for employment and, if you are hired, to perform the tasks essential to the job.
If you have a disability and require a reasonable accommodation to apply or interview with us, please let us
know by calling (772) 462-7282 or (772) 462-7280.
FLORIDA RETIREMENT SYSTEM (FRS) NOTIFICATION
Indian River State College is a Florida Retirement System (FRS) employer. If you have retired and are
receiving monthly benefits under the FRS Pension Plan or have taken any distribution (including a rollover)
under the FRS Investment Plan or optional non-
FRS Plans (State University System Optional Retirement
Plan, State Community College System Optional Retirement Plan, or Senior Management Service Optional
Annuity Program), please ensure you follow all state laws concerning termination requirements and
reemployment limitations if you accept employment with Indian River State College. For more information,
visit www.myfrs.com.
REFERRAL SOURCE
How did you hear about the position you are applying for?
Human Resources Office
IRSC Website
IRSC Employee Word of mouth:__________________________
IRSC Financial Aid Office Other:
List most recent job first.
EMPLOYMENT HISTORY
Name of Employer:
Address, City,
State:
Supervisor’s Name & Title:
Phone Number:
Your Job Title:
Employment Dates:
From
To
Hours Worked Per Week:
Full or Part-Time?
Salary/Hourly Rate:
Your Name at Time:
Reason for Leaving:
Duties and Responsibilities:
Name of Employer:
Address, City, State:
Supervisor’s Name & Title:
Phone Number: Your Job Title:
Employment Dates:
From
To
Hours Worked Per Week: Full or Part-Time?
Salary/Hourly Rate:
Your Name at Time:
Reason for Leaving:
Duties and Responsibilities:
REFERENCES
List professional
references
qualifications.
from persons familiar with your work and qualified to evaluate your
Name
Address
Occupation
Phone
Number
Years
Known
CERTIFICATION
I certify that the information contained in this application is correct and understand that falsification of this
information is sufficient grounds to prevent further consideration of employment at Indian River State
College for any and all present or future positions. Falsifications discovered in situations where employment
has been already extended become sufficient grounds for immediate dismissal in accordance with Indian
River State College policy. In consideration of my employment, I agree to conform
to the rules and
regulations of Indian River State College.
If I am employed with Indian River State College, I understand that IRSC is an “at will" employer. This means
that all student employees, are employed by and may be terminated at the will of IRSC without notice or
cause by either IRSC, or the employee, re
gardless of the length of their employment or the granting of
benefits of any kind. It also means the employees without contracts may resign without notice or stating
the reason.
Signature of Applicant Date
INDIAN RIVER STATE COLLEGE APPLICATION ADDENDUM
NON-DISCRIMINATION AND NON-HARASSMENT POLICY STATEMENT
It is the policy of Indian River State Coll
ege that each employee, visitor and student be allowed to participate
in college programs, activities and employment in a discrimination and harassment free environment.
Discrimination and harassment of any nature based on one’s race, color, national origin, ethnicity, sex,
pregnancy, religion, age, disability, sexual orientation, marital status, veteran status, genetic
information and any other factor protected under applicable federal, state and local civil rights laws,
rules and regulations is strictly prohibited.
Title IX of the Educational Amendments of 1972 is a federal law prohibiting discrimination on the basis
of sex in higher education. Sex discrimination includes sexual harassment and sexual violence. Indian
River State College prohibits the commission of any act of sexual assault, sexual misconduct, sexual
battery, and other crimes of violence upon employees, students and prospective students, visitors, and
other affiliates of the College conducting College business, events or activities on IRSC property or IRSC
sponsored events.
The following person has been designated to handle inquiries regarding non-discrimination and Title IX
complaints:
Adriene B. Jefferson
Equity Officer/Title IX Coordinator
Indian River State College
3209 Virginia Ave, Fort Pierce, FL 34981-5596
ajeffers@irsc.edu
(772) 462-7156
To view our Non-Discrimination and Non-Harassment policy and procedures, go to www.irsc.edu/About
IRSC/Equity at IRSC
. Copies of these are also available in the Office of Human Resources, located at 3209
Virginia Avenue, Fort Pierce, Florida.
click to sign
signature
click to edit
I
-
EQUAL EMPLOYMENT OPPORTUNITY INFORMATION
Your application will be considered even if you do not provide the information requested in this section
.
Female
Male
Please answer the two questions below. Regardless of your answer to Question 1, go to Question 2.
1. Ethnicity
Are you Hispanic or Latino (includes persons of Cuban, Mexican, Puerto Rican, South or Central
America, or other Spanish culture or origin, regardless of race).
Yes No
2. Race
Please select the racial category or categories with which you most closely identify by selecting the
appropriate box or boxes.
Please check one or more.
American Indian or Alaska Native
A person having origins in any of the original peoples of
North and South America (including Central America),
and who maintains tribal affiliation or community
attachment.
Asian
A person having origins 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.
Black or African American
A person having origins in any of the black racial groups
of Africa.
Native Hawaiian or Other Pacific Islander
A person having origins in any of the original peoples of
Hawaii, Guan, Samoa, or other Pacific Islands.
White
A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
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