Fill - Free fillable Application Generic (Central Oregon Community College) PDF form

WP/Forms/Employment Application/ 1 9/28/2015

COCC EMPLOYMENT APPLICATION

Please print clearly or type your application and sign it. You may also fill out this application by

duplicating or “scanning” it into your computer for completion.

Name:

Date:

Other Names Used: (This information is used to track transcripts)

Address:

City:

State and Zip Code:

Telephone Number

(include area code):

Message Telephone Number

(include area code):

E-Mail Address:

Position Applying For:

Interested in: Full Time Part Time Both Date Available:

Are you at least 18 years of age? Yes No

Where did you learn about this position?

Have you ever been employed by Central Oregon Community College? Yes No

If so, in what capacity:

Please provide us with the dates of employment:

Instructions to Applicants

Applicants are required to provide a complete application file by the deadline date. Please include a separate

STATEMENT OF EQUIVALENCY if applicable. PLEASE REFER TO THE VACANCY NOTICE FOR EXACT

REQUIREMENTS OF A COMPLETE APPLICATION FILE FOR EACH INDIVIDUAL OPENING.

Educational Background

High School Name

Location

Diploma or general

equivalency diploma (GED)?

Yes No

College/University Name and Location

Major

Degree(s)

Completed

Yes

No (If No, #

of Years

Completed)

Other Special Training and/or Study (Computer literacy, vocational experience, licenses, certificates)

Academic, Professional, Civic Organizations

WP/Forms/Employment Application/ 2 9/28/2015

Driver’s License (if applicable):

Number

State

References: (Reference type: work-related, education-related, etc.)

Name/Occupation

Telephone Number

Reference Type

Are you a U.S. military veteran? (COCC provides qualifying veterans and disabled veterans with preference in

employment. To receive veteran’s preference in this recruitment process, you must provide a copy of your

DD214 or DD215 form as supporting documentation.)

Yes No

If you have identified yourself as a qualified veteran or disabled veteran by submitting your DD214 or DD215

form as proof of veteran status, please describe any transferable skills earned during your military service

that you feel relate to the requirements/preferences of this position.

_____________________________________________________________________________________________

Employment History:

Please list each job you have held for the last TEN years OR list the LAST THREE JOBS, whichever is greater. If you

possess relevant experience outside of this time period, please feel free to include that job history as well. INCLUDE

periods of military service, education leave, and unemployment . Please fill out the application employment history as

thoroughly as possible. Your resume or vita should not be submitted in lieu of filling out the information. (If you need

more space, please use form 3A)

Present/Last Employer:

Supervisor’s Name:

Telephone Number:

(Please include area code)

Supervisor’s E-Mail Address:

Address:

City, State, & Zip Code:

Job Title:

Worked From: (Month/Year)

Worked To: (Month/Year)

Part Time Full Time

Duties:

Reason for Leaving:

If you still work here, may we contact this employer? Yes No

WP/Forms/Employment Application/ 3 9/28/2015

Previous Employer:

Supervisor’s Name:

Telephone Number:

(Please include area code)

Supervisor’s E-Mail Address:

Address:

City, State, & Zip Code:

Job Title:

Worked From: (Month/Year)

Worked To: (Month/Year)

Part Time Full Time

Duties:

Reason for Leaving:

If you still work here, may we contact this employer? Yes No

Previous Employer:

Supervisor’s Name:

Telephone Number:

(Please include area code)

Supervisor’s E-Mail Address:

Address:

City, State, & Zip Code:

Job Title:

Worked From: (Month/Year)

Worked To: (Month/Year)

Part Time Full Time

Duties:

Reason for Leaving:

If you still work here, may we contact this employer? Yes No

Previous Employer:

Supervisor’s Name:

Telephone Number:

(Please include area code)

Supervisor’s E-Mail Address:

Address:

City, State, & Zip Code:

Job Title:

Worked From: (Month/Year)

Worked To: (Month/Year)

Part Time Full Time

Duties:

Reason for Leaving:

If you still work here, may we contact this employer? Yes No

WP/Forms/Employment Application/ 4 9/28/2015

Certification

I certify that any and all statements, which I have set forth in this application, are true and correct to the best of my

knowledge. I also recognize that any omissions or false information provided herein may disqualify me as an

applicant and subject me to discharge in the event that I am hired.

Certification

I understand COCC employs only individuals who are lawfully eligible to work in the United States and that

employment eligibility will be verified upon employment. If I do not currently have permanent eligibility to work in the

U.S., I understand that it is my responsibility to obtain and/or maintain eligibility to work and that loss of eligibility to

work at any future date will invalidate my employment status and result in immediate separation from employment

without recourse or appeal.

I understand that COCC requires a criminal history check for this position, and if an offer of employment is made, this

will be contingent upon satisfactory completion of the criminal background check. I understand that background check

results are evaluated on a case-by-case basis alongside the job responsibilities, and that in selected circumstances,

felony convictions as related to the duties and responsibilities of a given position may influence consideration for

employment.

I understand that any falsification, misrepresentation, or material omission in my application materials (including this

certification) or making other false or fraudulent representations in securing employment may be grounds for

disqualification of my candidacy or (if discovered after the date of hire) invalidation of any employment status, without

recourse or appeal. My acknowledgment below authorizes COCC to conduct an inquiry into any information related to

my potential or continued employment with COCC, and I authorize the release of such information to COCC including

but not limited to, contacting references; verifying all of my application materials; obtaining prior education records

including degrees obtained; prior employment records including positions held, any disciplinary actions and reasons

for termination; driving record information, and obtaining information pertaining to convictions (including guilty or no

contest pleas). I agree that facsimiles or photocopies of this authorization shall be deemed as valid as the original. I

further release COCC and any of its agents from any liability whatsoever in requesting this information and using such

information for employment purposes.

I authorize COCC to check my references and to investigate any information provided in my application for

employment.

I also consent to any post-offer, pre-employment criminal history check when requested by the

College. I further authorize my past employers or anyone with information about my work history, education or

qualifications to provide such information to COCC in response to their inquiry.

I certify that I have read and agree with these statements. □

Signature of Applicant:

Date:

USE SPACE BELOW FOR ADDITIONAL DETAILS OR CLARIFICATIONS

SIGN AND SEND TO:

Office of Human Resources (Newberry 103) Telephone: 541-383-7216

Central Oregon Community College FAX Number: 541-317-3066

2600 NW College Way Website: www.cocc.edu/human-resources

Bend, OR 97701 TDD #: 541-383-7708

(for the hearing/speech impaired)

NONDISCRIMINATION POLICY

It is the policy of the Central Oregon Community College Board of Directors that there will be no discrimination or harassment on the basis of age,

disability, sex, marital status, national origin, ethnicity, color, race, religion, sexual orientation, genetic information, or veteran status or any other

protected classes under Federal and State statutes in any educational programs, activities or employment. Persons having questions about equal

opportunity and nondiscrimination should contact the Equal Employment Officer, c/o COCC's Human Resources office, 541.383.7216.

Faculty, staff and students are protected from discrimination and harassment under Title VII of the Civil Rights Act of 1964 and Title IX of the

Education Amendments of 1972. Persons attending classes or events who need accommodation for a specific disability should contact the office of

Services for Students with Disabilities at 541-383-7583. Persons needing physical accommodation for a College special event should contact ADA

Coordinator, Joe Viola at 541-383-7775. Further inquiries may be directed to the Affirmative Action Officer, c/o COCC’s Human Resources office, 541-

383-7216.

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