Attn: Human Resources Office
1555 South Raisinville Road
Monroe, MI 48161-9746
Telephone Number
Alternative Telephone Number
Email Address
Name:
Last First Middle
Address:
Number Street
City State Zip
Today's Date
Application for Faculty/Administrator/Professional Staff Positions
A person with a disability requiring accommodations for completing the application
and/or the interview process should notify the Oce of Human Resources
General Information
Position Desired: n Full-Time n Part-Time
Faculty: ________________________________________________________________________________________________________
Subject(s)-First Choice
Teaching: _______________________________________________________________________________________________________
Subject(s)-Second Choice
Administrator/Professional Sta: _____________________________________________________________________________________
Area
Are you at least 18 years of age? n Ye s n No
Are you legally eligible for employment in the United States? n Yes n No
(Proof of identity and eligibility will be required upon employment)
Will you now or in the future require sponsorship for employment visa status? n Yes n No
Have you ever been denied tenure or continuing contract status? n Yes n No
If yes, explain: ____________________________________________________________________________________________________
If selected for a position at Monroe County Community College, when would you be available for employment? _________________________
(734) 384-4110
FAX (734) 687-6057
Record of Education
College
or
University
Name of School Degree Earned
Monroe County Community College is an equal opportunity institution and adheres to a policy that no qualied person shall be discriminated against
because of race, color, religion, national origin or ancestry, age, gender, marital status, disability, genetic information, sexual orientation, gender identity/
expression, height, weight or veteran's status in any program or activity for which it is responsible. e College’s Equal Opportunity Ocer, Title IX,
and Section 504/ADA Compliance Ocer is the Director of Human Resources, phone 734.384.4245.
Name and Address of Employer and Type of Business
Briey describe the nature of the work.
Reason for Leaving
Name of School Degree Earned
Other
Formal
Education
Part-Time/Adjunct Teaching Experience
Assistantships/Student Teaching Experience
Record of Education
Name of Location Grade(s)
School City - State Subject(s) Dates
Name of Location Grade(s)
School City - State Subject(s) Dates
Bachelor
Degree Major ______________________________________ Minor _______________________________________________
Master
Degree Major ______________________________________ Minor _______________________________________________
Doctorate
Degree Major ______________________________________ Minor _______________________________________________
Dissertation Title _______________________________________ Advisor's Name ________________________________________
Past and Present Employment Beginning with most recent or current employer.
Name of Supervisor & Phone #
Fr o m To
Mo./Yr. Mo./Yr.
Name and Address of Employer and Type of Business
Briey describe the nature of the work.
Reason for Leaving
Name and Address of Employer and Type of Business
Briey describe the nature of the work.
Reason for Leaving
Past and Present Employment Beginning with most recent or current employer.
Name of Supervisor & Phone #
Name of Supervisor & Phone #
Fr o m To
Mo./Yr. Mo./Yr.
Fr o m To
Mo./Yr. Mo./Yr.
Teaching References List departmental chairpersons, superintendents, principals or instructors under whom you have taught.
Name of
Name Position College or University Area Code Phone No.
1.
2.
3.
Professional/Personal References Please list 3 business/work references who are not related to you and are not previous supervisors.
Name Relationship Phone No.
1.
2.
3.
e information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of
any fact in my application résumé, or any other materials, or during any interviews, can be justication for refusal of employment, or if employed,
termination from Monroe County Community College.
I give Monroe County Community College the right to contact and obtain information from all references, employers, educational institutions and to
otherwise verify the accuracy of the information contained in this application. I hereby release from liability Monroe County Community College and
its representatives for seeking, gathering and using such information and all other persons, employers, or organizations for furnishing such information.
Signed _________________________________________________________ Date _________________________________________
Pre-Employment Statement (Please Read Carefully)
#3053 - Rev 3/19
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