Fillable Application for Employment Faculty & Adjunct PERSONAL

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Application for Employment Faculty & Adjunct PERSONAL

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Southeastern Oklahoma State University is an Equal Opportunity Employer Page 1 of 7 Forms/Application for Employment FACULTY 9-2020
Application for Employment
Faculty & Adjunct
Al
l applications submitted must be signed on the appropriate signature line by the applicant, regardless of the delivery method. Applications should be
submitted by email, FAX, mail or personal delivery. Unsigned or incomplete applications will not be considered.
Please type or print in ink Date of Application: _________________________ Date Available for Employment: __________________________
PERSONAL
Name as shown on
Social Security Records:
(last) (first) (middle)
Mailing Address:
City, State, Zip:
Home Phone: Cell Phone: Business Phone:
E-mail Address:
POSITION
Specific position sought: _____________________________________________________________________________________
Where did you hear of this opening? Job Board Website Word of mouth Campus distribution Publication, please list_____________________
Are you willing and able, with or without accommodation, to perform necessary job-related travel? Yes No
Do you have a valid current Driver’s License? Yes No
ELIGIBILITY FOR EMPLOYMENT
Are you legally eligible for employment in the United States? Yes No
Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)? Yes No
Documentation of identity and employment eligibility must be provided upon hire as required by the Immigration Reform and Control Act of 1986
RELATIONSHIP TO UNIVERSITY EMPLOYEES
Are you related in any way to any University employee (includes in-laws)? Yes No
If yes, list name, relationship & department ___________________________________________
Regional University System Oklahoma & University policy states no two persons who are related by consanguinity or affinity within the third degree shall be given
positions in which either one is responsible for making recommendations regarding appointment, employment, promotion, salary or tenure for the other; nor shall either of
two persons so related who hold positions in the same internal budgetary unit be appointed to an executive or administrative position for said internal unit.
Relatives that are within the third degree of relationship to an employee by blood or marriage are as follows: Spouse; parent; grandparent; great-grandparent;
grandparent or great-grandparent of spouse; uncle or aunt; uncle or aunt of spouse; brother or sister; son or daughter; son-in-law or daughter-in-law; grandson or
granddaughter or their spouse; great-grandson or great-granddaughter or their spouse.
Return to: Human Resources
OR
Administration Building, 309
OR
email to: hr@se.edu
425 W. University Blvd. University Blvd. & 7
th
Avenue fax: (580) 745-7484
Durant, OK 74701-3347
Southeastern Oklahoma State University is an Equal Opportunity Employer Page 2 of 7 Forms/Application for Employment FACULTY 9-2020
EDUCATION AND TRAINING
Are you a high school graduate or have you passed a general education development (GED) test? Yes No
(will only be used as required by statute, law or bonafide job requirement)
Are you fluent in any language other than English? Yes No If yes, please specify:
Include high school, vocational school and college/university & graduate school. Verification of all levels of education may be required. Official transcript, diploma, or certification will be
required if offered a position, however, to meet application deadline, copies are acceptable.
Name of School, College, University,
and Graduate School
City, State
Number of
Hours
Completed
Diploma or Type of
Degree Received
Area of Study / Major
PROFESSIONAL LICENSE / CERTIFICATIONS
List any professional or occupational license, registration or certification (i.e., Certified Public Accountant, Certified Procurement Officer, etc.) and attach copies
Professional License,
Registration or Certification
Date
Received
License Number if
Applicable
Expiration
Date
Licensing Agency or Board
REFERENCES
Please list at least three professional references other than relatives or previous employers.
1. Name: 2. Name:
Address: Address:
City, State, Zip: City, State, Zip:
Telephone: ( ) email: Telephone: ( ) email:
Number of Years Acquainted: Number of Years Acquainted:
Occupation Occupation
3. Name: 4. Name:
Address: Address:
City, State, Zip: City, State, Zip:
Telephone: ( ) email: Telephone: ( ) email:
Number of Years Acquainted: Number of Years Acquainted:
Occupation Occupation
Southeastern Oklahoma State University is an Equal Opportunity Employer Page 3 of 7 Forms/Application for Employment FACULTY 9-2020
PROFESSIONAL ACCOMPLISHMENTS
List your thesis topic and the topic of your completed / proposed dissertation. Briefly describe your research goal:
List any textbooks, papers, articles or other publications you have authorized as a scholar. Please use bibliography format and attach additional sheets if
necessary:
List any special honors or awards you have received and your memberships (include offices you have held) in professional organizations or service clubs:
Southeastern Oklahoma State University is an Equal Opportunity Employer Page 4 of 7 Forms/Application for Employment FACULTY 9-2020
Give any other information concerning your qualifications that you think would be of value in considering you for this position:
EMPLOYMENT HISTORY
Have you previously worked for another Oklahoma state agency or a public college/university? Yes No
If ANY employment was under a different name, indicate name:
Have you ever been discharged or asked to resign from a job? Yes No If yes, explain below:
Describe your work experience in detail, beginning with your current or most recent job. Include military service (indicate rank) and volunteer work. List
each promotion or transfer as a separate job, even if they were with the same employer. If needed, attach additional copies of next page (pg 4).
Employers and supervisors may be contacted regarding your work experience
.
EMPLOYMENT HISTORY (list most recent employer first)
1. Employer Information (most recent):
Name: _____________________________________________________________
Address: ___________________________________________________________
Telephone: _____________________ Cell phone: __________________
Email address: _____________________________________________________
Supervisor Information:
Name: ______________________________________________________
Title: ______________________________________________________
Telephone: __________________ Cell phone: __________________
Email address: _____________________________________________
Are you still employed with this company? YES NO
If yes, may we contact your present employer as a reference? Yes No N/A
Job Title: ________________________________________________________
Employment Dates: From __________________ To: _________________
(month/year) (month/year)
Description of Duties and Work Performed (Be specific – attach extra signed and dated sheets, if necessary. Includes committee work):
Number of Employees Supervised: Ending Salary: $ per: hour month year Hours worked per week:
Reason for Leaving:
Southeastern Oklahoma State University is an Equal Opportunity Employer Page 5 of 7 Forms/Application for Employment FACULTY 9-2020
EMPLOYMENT HISTORY (continued)
2. Employer Information (most recent):
Name: _____________________________________________________________
Address: ___________________________________________________________
Telephone: __________________ Cell phone: __________________
Email address: _____________________________________________________
Supervisor Information:
Name: ______________________________________________________
Title: ______________________________________________________
Telephone: __________________ Cell phone: __________________
Email address: _____________________________________________
Are you still employed with this company? YES NO
If yes, may we contact your present employer as a reference? Yes No N/A
Job Title: ________________________________________________________
Employment Dates: From __________________ To: _________________
(month/year) (month/year)
Description of Duties and Work Performed (Be specific – attach extra signed and dated sheets, if necessary. Includes committee work):
Number of Employees Supervised: Ending Salary: $ per: hour month year Hours worked per week:
Reason for Leaving:
3. Employer Information (most recent):
Name: _____________________________________________________________
Address: ___________________________________________________________
Telephone: __________________ Cell phone: __________________
Email address: _____________________________________________________
Supervisor Information:
Name: ______________________________________________________
Title: ______________________________________________________
Telephone: __________________ Cell phone: __________________
Email address: _____________________________________________
Are you still employed with this company? YES NO
If yes, may we contact your present employer as a reference? Yes No N/A
Job Title: ________________________________________________________
Employment Dates: From __________________ To: _________________
(month/year) (month/year)
Description of Duties and Work Performed (Be specific – attach extra signed and dated sheets, if necessary. Includes committee work):
Number of Employees Supervised: Ending Salary: $ per: hour month year Hours worked per week:
Reason for Leaving:
Southeastern Oklahoma State University is an Equal Opportunity Employer Page 6 of 7 Forms/Application for Employment FACULTY 9-2020
EMPLOYMENT HISTORY (continued)
4. Employer Information (most recent):
Name: _____________________________________________________________
Address: ___________________________________________________________
Telephone: __________________ Cell phone: __________________
Email address: _____________________________________________________
Supervisor Information:
Name: ______________________________________________________
Title: ______________________________________________________
Telephone: __________________ Cell phone: __________________
Email address: _____________________________________________
Are you still employed with this company? YES NO
If yes, may we contact your present employer as a reference? Yes No N/A
Job Title: ________________________________________________________
Employment Dates: From __________________ To: _________________
(month/year) (month/year)
Description of Duties and Work Performed (Be specific – attach extra signed and dated sheets, if necessary. Includes committee work):
Number of Employees Supervised: Ending Salary: $ per: hour month year Hours worked per week:
Reason for Leaving:
* (If you have more than four separate periods of employment, complete a blank sheet in the above format; sign and attach to this application.)
Use this space for any additional information, comments, or explanations you may have that are pertinent to your application.
Southeastern Oklahoma State University is an Equal Opportunity Employer Page 7 of 7 Forms/Application for Employment FACULTY 9-2020
APPLICANT’S STATEMENT OF CERTIFICATION AND AGREEMENT
Accuracy of Information – By signing this application, I certify that the information supplied in this application and in any other form, oral or written, is
true and accurate.
Falsification of Information – I understand and agree that any misstated, misleading, incomplete or false information is grounds for my disqualification
from consideration for employment, for withdrawal of any offer of employment if an offer has been made, or for my immediate discharge if employment
has already commenced, whenever, and however discovered. I also understand that Section 358(B) of Title 21 of the Oklahoma Statutes prohibits
applicants for state employment from making a materially false, fictitious, or fraudulent statement or representation on any employment application,
knowing such statement or representation to be materially false, fictitious, or fraudulent. Violation is a criminal offence, punishable by fine and/or
imprisonment.
Verification of Information – I hereby authorize Southeastern Oklahoma State University to verify the information I have provided in my employment
application, in my oral statements and in any other documents or supplemental information I have provided to this agency for the purposes of
employment. This shall include the authorization to conduct any and all personal background checks, including but not limited to, criminal history and
related records, education and employment background records, civilian and military court records and/or proceedings. I authorize my former employers
and job-related references to provide any information requested by Southeastern Oklahoma State University. I release from liability and hold harmless
the State of Oklahoma, Southeastern Oklahoma State University, the Regional University System of Oklahoma Board, employees and attorneys, along
with any corporation, firm, person, organization or individual providing information to Southeastern Oklahoma State University, from any and all claims,
liabilities, loss, demands and causes of action known and unknown, fixed or contingent, equitable, legal or administrative, accrued to me as a result of
such disclosure of information concerning me.
Employment Eligibility – I understand that if I am hired I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance
with the Immigration Reform and Control Act of 1986. This agency verifies the identity and employment eligibility status of all newly hired employees
utilizing the Form I-9 verification process as well as the E-Verify Program with the Department of Homeland Security and the Social Security
Administration.
General – If selected for employment, I agree to conform to the policies, rules and regulations of Southeastern Oklahoma State University and the
Regional University System of Oklahoma. With this application, I agree to the University’s overtime pay policy for non-exempt employees, which allows
giving compensatory time off in lieu of payment of overtime worked. I understand that the position for which I am submitting this application may be at-
will. The applicant selected for any at-will position will serve at the will of the University. If selected for a position, I understand my employment and
compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either Southeastern Oklahoma State
University or myself. I understand that no representative of the University has any authority to enter into any agreement for continued employment for
any specified period of time or to make any agreement contrary to the foregoing. If an employee resigns or is discharged, full payment for unused
annual leave (excludes sick leave and personal leave) will be made upon approval of the Vice President for Business Affairs, provided the employee has
worked for a continuous six-month period and appropriate notice was given. No payment for annual leave will be authorized for any person who has not
completed at least six months of continuous employment at the University. Any compensatory time accrued and not used will be paid the month
following final paycheck.
Signature Required Date
In accordance with state and federal laws, the University will not discriminate in any employment practice, education program,
education activity, or admissions on the basis of race, color, religion, national origin, age, sex, sexual orientation, gender identity, or
veteran status. The following individual has been designated to handle inquiries regarding nondiscrimination policies: Mike Davis,
425 W. University Blvd. Durant OK, 74701, 580-745-3090, mdavis@se.edu
.
Title IX of the Education Amendments of 1972 protects people from sex discrimination in educational programs and activities at
institutions that receive federal assistance. The following individual has been designated to handle inquiries regarding Title IX: Mike
Davis, 425 W. University Blvd. Durant OK, 74701, 580-745-3090, mdavis@se.edu
.
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Southeastern Oklahoma State University
VOLUNTARY INFORMATION REQUEST: NOT TO BE USED IN HIRING DECISIONS
Equal Employment Opportunity Information Request
As a government contractor, Southeastern Oklahoma State University is subject to Executive Order 11246, as amended, which requires government
contractors to take affirmative action in the employment process. We request your VOLUNTARY completion of the following questionnaire to be used ONLY
for the purpose of monitoring the success of our Affirmative Action plan. This information will not be used to discriminate against or to show preference for
any application in the hiring decision.
POSITION AND DEPARTMENT
NAME:
Gender
Male
CITIZENSHIP: United States
Race/Ethnic Date (Select only one):
Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race
Native American Indian or Alaska Native (Not Hispanic or Latino (Not Hispanic or Latino) (A person having origins in any of the original peoples of North and South
America (including Central America), and who maintain tribal affiliation or community attachment.)
Asian
((Not Hispanic or Latino) (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for
example Cambodia, China Indian Japan, Korea, Malaysia,Pakistan, the Philippine Islands, Thailand and Vietnam.)
African American or Black (Not Hispanic or Latino) (A person having origins in any of the black racial groups of Africa.)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) (A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White or Caucasian (Not Hispanic or Latino) (A person having origins in any of the original peoples of Europe,the Middle East or North Africa.)
Two or More Races (Not Hispanic or Latino) (All persons who identify with more than one of the above five races.)
I do not wish to enter voluntary self-Identification EEOC information.
Do you qualify as a Veteran?
February 28, 1961 and May 7, 1975 and was discharged for release therefrom with other than a dishonorable discharge, or was discharged or released from active duty for a service-connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975.)
Please indicate how you learned of this opening:
_____________________________________________________________________________________________________________________
Email to: hr@se.edu or fax to 580-745-7484
EEO Voluntary Information Request From S:EEO Form July 2016
Yes
No
Vietnam Veteran (A Vietnam Veteran is any veteran of the US armed services who served on active duty for at least 180 days, any part of which occurred between
February 28, 1961 and May 7, 1975 and was discharged for release therefrom with other than a dishonorable discharge, or was discharged or released from active
duty for a service-connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975
Yes
No
If No, What Country?
Female
Do you consider yourself to be a person with a disability?
Yes
No
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Application for Employment Faculty & Adjunct PERSONAL

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Completed 26 July 2021

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