Fillable Application With Consent Form Revised 1-2021 (Bishop State Community College)

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Application With Consent Form Revised 1-2021 (Bishop State Community College)

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Alabama Community College System
Application No.
APPLICATION FOR EMPLOYMENT
Bishop State Community College
Position
Information
Title of position for which you are applying:
Date of Application
Personal
Information
Last Name
First Name
Middle Initial
Address
State
Zip
Contact Information
Phone: Home
Work
Cell
E-mail Address
Secondary and
Postsecondary Education
School/College
Dates Attended
From / To
Major
Minor
Degree(s)
Earned
High
School/
GED
College
College
College
Other
(Specify)
Additional
Information
Are you currently employed or have been employed within the last twelve months at an Alabama
Community College System college?
Yes No
If yes, list the name of the college(s) and dates: ____________________________________________________
Employment History
Please list most recent employment experience first.
Employer
Telephone Number
Job Duties
Address
Dates of
Employment
Title
Full-time
Part-time
Hr. Rate/Salary
(optional)
Reason for Leaving
Employment History
(Continued)
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary (optional)
Reason for Leaving
Employment History
(Continued)
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary (optional)
Reason for Leaving
Employment History
(Continued)
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary (optional)
Reason for Leaving
Employ
ment History
(Continued)
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary
(optional)
Reason for Leaving
May we contact your current employer? Yes No
S
kills, Awards
,
Certificates
or
Professional
Activities
Note: Please provide details of each. May use a separate sheet if necessary.
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 (Bishop State
Community 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
Visit the ACCS website at www.accs.edu
and click ‘Job Postings’ to sign up for email alerts.
Bishop State Community College
Attention Human Resources
351 N. Broad Street
Mobile, AL 36603
(251) 405-7052
(Institution Name) is an equal opportunity employer. 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, shall be discriminated against on the basis of any impermissible criterion or characteristics including,
without limitation, race, color, national origin, religion, martial status, disability, sex, age or any other protected class as defined by federal
and state law. (Institution Name) will make reasonable accommodations for qualified disabled applicants or employees.
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REQUEST, AUTHORIZATION, CONSENT, AND RELEASE
FOR BACKGROUND INFORMATION
I have been informed and acknowledged that on April 13, 2016 the Alabama Community College System
Board of Trustees adopted Policy 623.01 requiring criminal background checks for all new and current
employees.
By signing this authorization, I hereby authorize the Alabama Community College System or its designee,
to conduct criminal reference searches for felony and misdemeanor convictions at the statewide and
national levels of every jurisdiction where I currently reside or where I have previously resided during the
past seven years; national sex offender registry searches and a search of my driving record.
I understand that I may voluntarily consent to the use of my social security account number for the
purpose of conducting a criminal background check. I further understand that my voluntary consent to
use my social security account number is being requested for purposes of conducting a criminal
background check, pursuant to the authority of the Alabama Community College System Board of
Trustees policy regarding criminal background checks. I understand that neither the Alabama Community
College System nor any employing authority within the Alabama Community College System will deny me
any right, benefit or privilege provided by law because of my refusal to voluntarily consent to the use of
my social security account number for the limited purpose of conducting a criminal background check
pursuant to the Alabama Community College System Board of Trustees policy regarding criminal
background checks.
______I voluntarily consent to the use of my social security account number for the limited
purpose of conducting a criminal background check. Social Security #_______________
______I do not consent to the use of my social security account number for the limited purpose of
conducting a criminal background check.
______I consent to the use of my driver’s license number to be used for the limited purpose of
conducting a review of my driving history.
_____ I do not consent to the use of my driver’s license number for the limited purpose of
conducting a review of my driving history.
The information I have given in my employment application, interviews, and/or related resumes and
documents is true, complete, and accurate.
I understand and agree that if employed, and/or during any period of employment, any false statements,
misrepresentations of facts, or omission made by myself become known, my employment shall be subject
to immediate termination.
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 have read and completely understand this release.
Applicant’s Signature: __________________________________ Date: __________________
Applicant’s Name (Please print): ___________________________________________________
Applicant’s Address: ____________________________________________________________
Applicant’s Birthday: ____________________________________________________________
Applicant’s Driver’s License Number: _______________________________________________
Applicant’s Driver’s License State: _________________________________________________
Revised March 2019
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Application With Consent Form Revised 1-2021 (Bishop State Community College)

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Completed 2 February 2021

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