Application for Employment - Crowder College
601 Laclede Avenue ~ Neosho, Missouri 64850
(417) 455-5726 ~ FAX (417) 455-5747
www.crowder.edu
Instructions
Unless otherwise instructed, please return these application materials to the Human Resources Office at the above
address.
Completion of this application form is required, even if a resumé is submitted.
For positions requiring degrees, please submit a copy of transcripts documenting post-secondary education
preparation, certificates and licenses; official documents will be required should applicant be extended a contract.
Application materials submitted for consideration become the property of the college and will not be returned.
Please review the job announcement and attach any other application materials requested.
Personal Data Date of application:
______________________________
Position applying for: __________________________________________________________________________________
Name:_______________________________________________________________________________________________
Last First Middle Birth or Other Name
Mailing address:_______________________________________________________________________________________
Street or P.O. # City State Zip Code
Phone: Work:________________________ Home: ________________________ Cell: __________________________
E-mail: __________________________________________ Social Security Number: ___________________________
Have you previously been an employee of Crowder College in any capacity and at any location?
Yes No
If yes, please list position(s) held and dates of employment: ____________________________________________________
List any relatives currently employed at Crowder College:
Name Relationship
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Proof of citizenship or immigration status will be required upon employment:
Are you a citizen of the U.S.?
Yes No
If not, are you legally permitted to be employed in the U.S.?
Yes No
What type of visa do you possess? _______________________________________________________
(Proof of citizenship or immigration status will be required upon employment.)
How did you become aware of this position?
___________________________________________________________________
Are you able to perform the essential functions of the position you are applying for either with or without reasonable
accommodations?
Yes No
Academic Preparation
As stated in the instructions on page 1, for positions requiring degrees, please submit a copy of transcripts documenting post-
secondary education preparation, certificates and licenses; official documents will be required should applicant be extended a
contract. High school and colleges or universities attended:
Name of Institution
State
Major Field
Did you
Graduate?
Degree Received
Or hours completed
Yes No
HS Equivalent
High School
Yes No
Yes No
Yes No
Please list oth
er education or specialized training relevant to this position as well as relevant publications, awards, honors,
professional memberships (professional, trade, business, civic), and experience with computer software/operating systems:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Employment History
Please comp
lete the information below. List work experience (full-time and part-time) starting with the most recent
experience. If more space is needed, maintain the same sequence and format on an attached sheet.
Employ
er ________________________________________________ Phone #:
__________________________________
-time From ____________________ To ________________________
City/State: _____________________________________ Supervisor: ___________________________________________
Your Job Title ____________________________________________ Duties ______________________________________
Reason for leaving ____________________________________________________________________________________
Employ
er ________________________________________________ Phone #:
__________________________________
-time From ____________________ To ________________________
City/State: _____________________________________ Supervisor: ___________________________________________
Your Job Title ____________________________________________ Duties ______________________________________
Reason for leaving ____________________________________________________________________________________
Employ
er ________________________________________________ Phone #:
__________________________________
-time From ____________________ To ________________________
City/State: _____________________________________ Supervisor: ___________________________________________
Your Job Title ____________________________________________ Duties ______________________________________
Reason for leaving ____________________________________________________________________________________
Please exp
lain any periods of unemployment:_______________________________________________________________
____________________________________________________________________________________________________
College/Post-Secondary Training
References: Submit three references who can speak to your abilities to perform the duties associated with this position. (A
resumé will not serve as a substitute.)
Name: ______________________________________________________ Phone # ______________________________
Home Work Cell
Title: __________________________________________ Employer_____________________________________________
How long have you known this individual and in what capacity?
____________________________________________________________________________________________________
Name: ___
___________________________________________________ Phone # ______________________________
Home Work Cell
Title: __________________________________________ Employer_____________________________________________
How long have you known this individual and in what capacity?
____________________________________________________________________________________________________
Name: ___
___________________________________________________ Phone # ______________________________
Home Work Cell
Title: __________________________________________ Employer_____________________________________________
How long have you known this individual and in what capacity?
____________________________________________________________________________________________________
Declaration Statements
The information provided in the Application for Employment is true and complete. I authorize Crowder College to
investigate all statements made in this application and in any interview(s) related to this application and to seek information
to determine my suitability for this position. I also hereby release from liability Crowder College and its representatives from
seeking, gathering, and using such information to make employment decisions and all persons or organizations for providing
such information. I understand if I am employed, any misstatement, misleading information, or omission of fact on this
application and/or in interview(s) may result in my immediate termination and disqualify me for any future employment
opportunities at Crowder College. I understand this application or an invitation to interview does not constitute an offer of
employment or contract. Should I be hired by Crowder College, I agree to submit any original documentation required for
employment. I also agree to abide by all the regulations of the college, including but not limited to the institution’s substance
abuse, discrimination, and sexual harassment policies.
Crowder College requires a pre-employment background check for all new employees and some positions may require a pre-
employment drug screening and/or a consumer credit report. Crowder College does not deny employment solely on the
grounds of a conviction or guilty plea of a criminal offense. The nature of the offense, the date of the offense, the surrounding
circumstances and the relevance of the offense to the position applied for will be considered. In the event that potential
employment, the College will provide you with a copy of the consumer report and a description in writing of your rights
under the Federal Fair Credit Reporting Act. In relation to the position I am applying for, I acknowledge that a clear
background check and/or drug screening will be required for employment.
Crowder College is an equal opportunity employer/program. Auxillary aides and services are available upon request for
individuals with disabilities. Missouri relay services available at 711. Crowder College does not discriminate on the basis of
race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), genetic information, military service,
national origin, ancestry, age, disability, or any other legally protected class. Crowder College is an at-will employer under
the statutes of the State of Missouri and has zero tolerance for drug use or sexual harassment. Crowder College complies with
Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments Act of 1972 regarding sex discrimination,
and the Americans with Disability Act of 1990. Questions related to the institution’s efforts to comply with employment
statutes should be directed to Michelle Paul, EEO Officer, Human Resources Office, at Crowder College.
I certify that I meet the educational and work experience requirements as stated in the job description/announcement and that
I have read, fully understand and accept all terms of the foregoing statements.
My signature below indicates my understanding of the above statements. Undated and unsigned applications will not be
considered. Should you be invited for a formal interview, a skills demonstration and/or testing may be required. Cost
associated with the application/interview process are the responsibility of the applicant.
________________________________________________________________ ___________________________
Signatu
re Date
click to sign
signature
click to edit
CROWDER COLLEGE SELF IDENTIFICATION REPORT
We consider all applicants for positions without discrimination based on race, color, religion, sex (including pregnancy,
gender identity, and sexual orientation), national origin, age, ancestry, disability, genetic information, military service or any
other legally protected status.
To assist Crowder College in its effort to comply with federal and state requirements regarding government recordkeeping,
reporting and other legal obligations, we invite you to supply the following information. Providing this information is strictly
voluntary. Failure to provide it will not subject you to any adverse personnel decision or action.
Please be advised that this report is not a part of your official application for employment. It will not be used in any hiring
decision. The information will be kept separate from your other application materials and used for the above reported
purposes only and kept confidential in accordance with applicable laws and regulations. It will not be shared with the
selection committee for any position for which you apply.
Ap
plicant Information: Name: ____________________________________
Gender:
Male Female Birthdate: ____________________
Are you Hispanic / Latino?
Yes No
Please check all that apply below. Are you:
A Vietnam Era Veteran
I am a veteran of the Vietnam era; i.e., I served
on active duty for more than 180 days, some
part of which occurred between August 5, 1964,
and May 7, 1975, and I was discharged with
other than dishonorable discharge, or I was
released from active duty for a service-
connected disability during the same period.
Disabled Veteran
I am a disabled veteran; entitled to disability
compensation under the laws administered by
the Veterans Administration for a disability
rated at 30% or more, or I was discharged or
released from active duty for a disability
incurred or aggravated in the line of duty.
Disabled
I am a disabled person, with a physical or
mental impairment which substantially limits
one or more of major life activities.
Please check one or more of the below which
apply to you:
Asian
A person with origins in any of the original
peoples of the Far East, Southeast Asia, or the
Indian Subcontinent.
Black or African American (Non-Hispanic)
A person with origins in any of the black racial
groups of Africa who is not of Hispanic origin.
American Indian or Alaska Native
A person with origins in any of the original
peoples of North America or who maintains
cultural identification through tribal affiliation
or community recognition.
Native Hawaiian or Other Pacific Islander
A person with origins in the Hawaiian Islands or
other Pacific Islands.
Hispanic/Latino
A person of Mexican, Puerto Rican, Cuban,
Central or South American, or other Spanish
culture or origin regardless of race.
White (Non-Hispanic)
A person with origins in any of the original
peoples of Europe, North Africa, or the Middle
East who is not of Hispanic origin.
Tha
nk you.
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