911 South Tenth Street, Tucumcari, NM 88401
(575) 461-4413; FAX: (575) 461-1901
www.mesalands.edu
Application for Employment
Mesalands Community College is committed to the policy of equal opportunity in employment and education regardless of race,
color, religion, national origin, sex, age, physical or mental disability, serious medical condition or veteran status. The College
will endeavor to maintain the confidentiality of the information contained in this application to the extent permitted by law.
Personal Data
Position for which you are applying Date Available for Employment
Name/Address
Last First Middle
Address City State Zip
List any former name(s) which may appear on educational and prior employment records:
Permanent Address (if different)
Phone
Home Work Message
E-mail address:_____________________________________________________________
Are you under the age of 18? Yes
No
Have you previously worked for Mesalands Community College? Yes
No ; If yes, when?
Please list the following information for any of your relatives currently employed at Mesalands Community College or serving on the Board of Trustees:
Name Relationship Name Relationship
Work Experience
Beginning with the most recent, list complete information for all employment for the past ten years. Please use additional
copies of page 2 to complete your 10-year employment history. Resumes may NOT be submitted in place of employment
history, but may be required as part of the application package (attach additional sheets if necessary). Final candidates will
have their current and former employers contacted.
Name of present or last employer
Address
City/State/Zip
Job title and nature of work done
Phone number:
Dates of employment: From To
Rate of pay: $
Number of hours per week Name of supervisor
List reason for leaving employment:
Mesalands Community College Application for Employment Page 2
Name of previous employer Address
City/State/Zip
Job title and nature of work done
Phone number:
Dates of employment: From To
Rate of pay: $
Number of hours per week Name of supervisor
List reason for leaving employment:
Name of previous employer
Address
City/State/Zip
Job title and nature of work done
Phone number:
Dates of employment: From To
Rate of pay: $
Number of hours per week Name of supervisor
List reason for leaving employment:
Name of previous employer
Address
City/State/Zip
Job title and nature of work done
Phone number:
Dates of employment: From To
Rate of pay: $
Number of hours per week Name of supervisor
List reason for leaving employment:
Name of previous employer
Address
City/State/Zip
Job title and nature of work done
Phone number:
Dates of employment: From To
Rate of pay: $
Number of hours per week Name of supervisor
List reason for leaving employment:
Name of previous employer
Address
City/State/Zip
Job title and nature of work done
Phone number:
Dates of employment: From To
Rate of pay: $
Number of hours per week Name of supervisor
List reason for leaving employment:
Explain all gaps in employment during the last 10 years, including unemployment, military service, education, etc.: _______
Mesalands Community College Application for Employment Page 3
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Education
Please indicate the highest level of education completed:
High school diploma
GED certificate
Associate degree
Bachelor degree
Master’s degree
Doctorate
Please list for each post-secondary degree earned: degree, field of study, institution, and year the degree was awarded:
Degree
Field of Study Institution Year
Professional Certifications
Please list any professional certifications you have, the document number, and the date of expiration:
Certification
Document Number Date of Expiration
Special Skills
Please check the boxes below for the skills in which you feel you have reached proficiency:
Typing: wpm ______
Windows Operating
System
Word Processing
Computer Data Entry
Spreadsheets
Database
Desktop Publishing
Computer Graphics
Presentation Software
Shorthand
Dictaphone
Cash Register
Calculator
Library
Electricity
Plumbing
Painting
Mechanical
Welding
Carpentry
Custodial
Groundskeeping
Bronze Foundry
Other
Mesalands Community College Application for Employment Page 4
4/12/10 kak
Additional Information
Please give any additional information that more fully describes your interests and qualifications. If job description
indicates a valid driver license is required, please list pertinent information (Use additional sheets of paper if necessary.)
How did you learn of this job position? ___________________________________________________________________
Professional References
Please list three professional references that know your qualifications and work experience for the position for which you
are applying:
Name Address
City/State/Zip
Phone
How does this reference know your qualifications and experience?
Name Address
City/State/Zip
Phone
How does this reference know your qualifications and experience?
Name Address
City/State/Zip
Phone
How does this reference know your qualifications and experience?
IMPORTANT: In most cases other application materials are required for a complete application. Please refer to the appropriate
job announcement or advertisement for complete application requirements. All transcripts and records from high schools,
colleges, and/or universities received by Mesalands Community College will become the property of the institution. No
transcripts will be released. Applicants who desire copies of their transcripts should write directly to the institutions attended.
Applicant's Certification
I certify that the information contained in this application is correct and complete to the best of my knowledge and belief. I
understand that knowingly making a false statement or omission in this application may be sufficient cause for rejection of the
application or dismissal after employment. By signing this application, I authorize Mesalands Community College to conduct a
background investigation, including reference and employment checks, verification of education, and a criminal check.
Signature Date
Social Security Number
click to sign
signature
click to edit
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