WP/Forms/Employment Application/ 1 9/28/2015
COCC EMPLOYMENT APPLICATION
Please print clearly or type your application and sign it. You may also fill out this application by
duplicating or “scanning” it into your computer for completion.
Name:
Date:
Other Names Used: (This information is used to track transcripts)
Address:
City:
State and Zip Code:
Telephone Number
(include area code):
Message Telephone Number
(include area code):
E-Mail Address:
Position Applying For:
Interested in: Full Time Part Time Both Date Available:
Are you at least 18 years of age? Yes No
Where did you learn about this position?
Have you ever been employed by Central Oregon Community College? Yes No
If so, in what capacity:
Please provide us with the dates of employment:
Instructions to Applicants
Applicants are required to provide a complete application file by the deadline date. Please include a separate
STATEMENT OF EQUIVALENCY if applicable. PLEASE REFER TO THE VACANCY NOTICE FOR EXACT
REQUIREMENTS OF A COMPLETE APPLICATION FILE FOR EACH INDIVIDUAL OPENING.
Educational Background
Location
Diploma or general
equivalency diploma (GED)?
Yes No
College/University Name and Location
Major
Degree(s)
Completed
Yes
No (If No, #
of Years
Completed)
Other Special Training and/or Study (Computer literacy, vocational experience, licenses, certificates)
Academic, Professional, Civic Organizations
WP/Forms/Employment Application/ 2 9/28/2015
Driver’s License (if applicable):
Number
State
References: (Reference type: work-related, education-related, etc.)
Name/Occupation
Telephone Number
Reference Type
Are you a U.S. military veteran? (COCC provides qualifying veterans and disabled veterans with preference in
employment. To receive veteran’s preference in this recruitment process, you must provide a copy of your
DD214 or DD215 form as supporting documentation.)
Yes No
If you have identified yourself as a qualified veteran or disabled veteran by submitting your DD214 or DD215
form as proof of veteran status, please describe any transferable skills earned during your military service
that you feel relate to the requirements/preferences of this position.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Employment History:
Please list each job you have held for the last TEN years OR list the LAST THREE JOBS, whichever is greater. If you
possess relevant experience outside of this time period, please feel free to include that job history as well. INCLUDE
periods of military service, education leave, and unemployment . Please fill out the application employment history as
thoroughly as possible. Your resume or vita should not be submitted in lieu of filling out the information. (If you need
more space, please use form 3A)
Present/Last Employer:
Supervisor’s Name:
Telephone Number:
(Please include area code)
Supervisor’s E-Mail Address:
Address:
City, State, & Zip Code:
Job Title:
Worked From: (Month/Year)
Worked To: (Month/Year)
Part Time Full Time
Duties:
Reason for Leaving:
If you still work here, may we contact this employer? Yes No
WP/Forms/Employment Application/ 3 9/28/2015
Previous Employer:
Supervisor’s Name:
Telephone Number:
(Please include area code)
Supervisor’s E-Mail Address:
Address:
City, State, & Zip Code:
Job Title:
Worked From: (Month/Year)
Worked To: (Month/Year)
Part Time Full Time
Duties:
Reason for Leaving:
If you still work here, may we contact this employer? Yes No
Previous Employer:
Supervisor’s Name:
Telephone Number:
(Please include area code)
Supervisor’s E-Mail Address:
Address:
City, State, & Zip Code:
Job Title:
Worked From: (Month/Year)
Worked To: (Month/Year)
Part Time Full Time
Duties:
Reason for Leaving:
If you still work here, may we contact this employer? Yes No
Previous Employer:
Supervisor’s Name:
Telephone Number:
(Please include area code)
Supervisor’s E-Mail Address:
Address:
City, State, & Zip Code:
Job Title:
Worked From: (Month/Year)
Worked To: (Month/Year)
Part Time Full Time
Duties:
Reason for Leaving:
If you still work here, may we contact this employer? Yes No
WP/Forms/Employment Application/ 4 9/28/2015
Certification
I certify that any and all statements, which I have set forth in this application, are true and correct to the best of my
knowledge. I also recognize that any omissions or false information provided herein may disqualify me as an
applicant and subject me to discharge in the event that I am hired.
Certification
I understand COCC employs only individuals who are lawfully eligible to work in the United States and that
employment eligibility will be verified upon employment. If I do not currently have permanent eligibility to work in the
U.S., I understand that it is my responsibility to obtain and/or maintain eligibility to work and that loss of eligibility to
work at any future date will invalidate my employment status and result in immediate separation from employment
without recourse or appeal.
I understand that COCC requires a criminal history check for this position, and if an offer of employment is made, this
will be contingent upon satisfactory completion of the criminal background check. I understand that background check
results are evaluated on a case-by-case basis alongside the job responsibilities, and that in selected circumstances,
felony convictions as related to the duties and responsibilities of a given position may influence consideration for
employment.
I understand that any falsification, misrepresentation, or material omission in my application materials (including this
certification) or making other false or fraudulent representations in securing employment may be grounds for
disqualification of my candidacy or (if discovered after the date of hire) invalidation of any employment status, without
recourse or appeal. My acknowledgment below authorizes COCC to conduct an inquiry into any information related to
my potential or continued employment with COCC, and I authorize the release of such information to COCC including
but not limited to, contacting references; verifying all of my application materials; obtaining prior education records
including degrees obtained; prior employment records including positions held, any disciplinary actions and reasons
for termination; driving record information, and obtaining information pertaining to convictions (including guilty or no
contest pleas). I agree that facsimiles or photocopies of this authorization shall be deemed as valid as the original. I
further release COCC and any of its agents from any liability whatsoever in requesting this information and using such
information for employment purposes.
I authorize COCC to check my references and to investigate any information provided in my application for
employment.
I also consent to any post-offer, pre-employment criminal history check when requested by the
College. I further authorize my past employers or anyone with information about my work history, education or
qualifications to provide such information to COCC in response to their inquiry.
I certify that I have read and agree with these statements.
Signature of Applicant:
Date:
USE SPACE BELOW FOR ADDITIONAL DETAILS OR CLARIFICATIONS
SIGN AND SEND TO:
Office of Human Resources (Newberry 103) Telephone: 541-383-7216
Central Oregon Community College FAX Number: 541-317-3066
2600 NW College Way Website: www.cocc.edu/human-resources
Bend, OR 97701 TDD #: 541-383-7708
(for the hearing/speech impaired)
NONDISCRIMINATION POLICY
It is the policy of the Central Oregon Community College Board of Directors that there will be no discrimination or harassment on the basis of age,
disability, sex, marital status, national origin, ethnicity, color, race, religion, sexual orientation, genetic information, or veteran status or any other
protected classes under Federal and State statutes in any educational programs, activities or employment. Persons having questions about equal
opportunity and nondiscrimination should contact the Equal Employment Officer, c/o COCC's Human Resources office, 541.383.7216.
Faculty, staff and students are protected from discrimination and harassment under Title VII of the Civil Rights Act of 1964 and Title IX of the
Education Amendments of 1972. Persons attending classes or events who need accommodation for a specific disability should contact the office of
Services for Students with Disabilities at 541-383-7583. Persons needing physical accommodation for a College special event should contact ADA
Coordinator, Joe Viola at 541-383-7775. Further inquiries may be directed to the Affirmative Action Officer, c/o COCC’s Human Resources office, 541-
383-7216.
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