References
Please list three references, other than relatives, who can provide information verifying qualifications,
character, or work experience.
Name and Title Address Phone Number
Family
Relationship
For the purposes of disclosure, relative includes any person related within the fourth degree of affinity or
consanguinity to any job, position, or office of profit with state or with any of its agencies.
Are you a relative of any employee in the Alabama Community College system, including (name of college), or
any member of the Alabama Community College System Board of Trustees? Yes No
If yes, list the name(s), relationship, and employer/position of relative(s):
Felony
Conviction(s)
Have you ever been convicted of or pled no contest or guilty to any felony or any crime involving theft,
dishonesty, violence, or sexual misconduct? Yes No
If yes, explain below:
Consent Agreement
I represent and warrant that the information I have given on this application is full and true to the best of my knowledge and
belief. I further acknowledge that I understand that I must provide documented verification of education, experience, and
required certifications and/or licensures. And further, I represent and warrant that I have answered fully and truthfully all
questions regarding criminal convictions/records. I understand that any offer of employment is contingent upon a
satisfactory criminal background investigation and I hereby authorize my employing authority within the Alabama
Community College System and/or its assigns to conduct a criminal background history investigation. I understand
that in the event a conviction for a felony or any crime involving moral turpitude is found that the procedures
established for the Board of Trustees policy concerning criminal background checks will be followed. I further
understand that I will be responsible for the cost of said criminal background check. I hereby expressly request, and
give permission to, former employers and any persons who may have pertinent information concerning this application to
furnish such information to college officials. I agree to hold such persons harmless, and I do hereby release them from any
and all liability for damage of any nature whatsoever for furnishing such information. I understand that failure to provide full
and true information on this application may result in disqualification or dismissal.
Signature of Applicant Date
Are you a member of the Alabama Community College System Applicant Pool? Yes No
Gadsden State Community College
Attention: Human Resources
P.O. Box 227
Gadsden, AL 35902-0227
Phone: (256) 549-8235 Fax: (256) 439-6812
It is the policy of the Alabama Community College System, including all postsecondary community and technical colleges under the control of the Alabama
Community College System Board of Trustees, that no employee or applicant for employment or promotion, on the basis of any impermissible criterion or
characteristic including, without limitation, race, color, national origin, religion, marital status, disability, sex, age, or any other protected class as defined by
federal and state law, shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program, activity, or
employment. (Each institution will make reasonable accommodations for qualified disabled applicants or employees.)
