BISHOP STATE COMMUNITY COLLEGE
EMPLOYEE PERSONNEL DATA FORM
SSN: __ __ __-__ __- __ __ __ __
Name: ____________________________________________ DOB: ____/___/_______
Street Address: _______________________________________ Apartment/Unit #:____________
City: _______________________ State: _____ Zip: ___________ Sex:__________
Phone No:
(______)_________________ E-mail Address: _________________________________
Ethnicity/Race (check all that apply): Are you Hispanic/Latino? Yes No
American Indian/Alaska Native Asian Black/African-American White Native Hawaiian/Pacific Islander
Emergency Notification:
Notify: _________________________ Phone:(_______)_______________ Relationship:_______________
Highest Degree Received (choose from listing below): ___________
AA
Associate in Arts
EDS
Education Specialist Degree
AAS
Associate in Applied Science
HS
Graduated High School or received GED
AAT
Associate in Applied Technology
LLD
Law Degree
AO
Other Associate Degree
M30
Master’s Degree Plan 30 hours
AS
Associate in Science
M60
Masters Plus 60 hours
BA
Bachelor of Arts
MA
Masters in Art
BO
Baccalaureate Degree
MO
Other Master’s Degree
BS
Bachelor of Science
MS
Master in Science
CC
Certificate of 12-18 month program
OD
Doctorate Other
CT
Certificate less than 12 months
OP
Other Professional Degree beyond Master and below Doctorate
DPL
Diploma or certificate for 18 months
PHD
Doctorate Other
EDD
Education Doctorate
ZZZ
Below High School
Yes No
Are you currently contributing to the Teachers’ Retirement System of Alabama?
If yes, How many years have you been contributing to the Teachers’ Retirement System of
Alabama?
If no, Have you in the past contributed to the Teachers’ Retirement System of Alabama?
Are you a Retiree of the Teachers’ Retirement System of Alabama?
If yes to any of the above questions, have you withdrawn from your account?
Were you an active member of the Teachers’ Retirement System of Alabama on or before January
1, 2013?
Are you currently working part-time or full-time at another institution in the two-year Alabama
College System?
Are you currently contributing to the Employee’s Retirement System of Alabama?
Employee Number: ______________ Date of Hire: ____________ TRS TIER 1:______ TRS TIER 2: ______
BISHOI_)
STATE
We are so
ex
cited to have y
ou
on aboard with us!
Pl
ease give us a little
inf or
ma
tion abo
ut
yourse
lf
so t
hat
we can share and int
ro
du
ce
you
't
o the
Bi
shop
State
f amity.
Department:
\.
Position:
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Name:
I am a na
tiv1;;
.of (city & state):
List institutions and degrees
ea
rn
ed
:
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REQUEST, AUTHORIZATION, CONSENT,
AND
RELEASE
FOR BACKGROUND INFORMAT
IO
N
I have been informed and acknowledged that
on
April
13
, 2016
the
Alabama Community College System
Board of Trustees adopted Policy 623.
01
requiring criminal background checks for all new
and
current
employees. ( (
By
signing this authorization, I hereby authorize the Alabama Community
Co
ll
ege System or
its
designee,
to conduct criminal reference searches for felony and misdemeanor convictions at the statewide
and
national levels of every jurisdiction where I currently reside or where I have previously resided during the
past seven years; national sex offender registry searches and a search of my driving record.
I understand that I may voluntarily consent to the use
of
my social security account number for the
purpose of conducting a criminal background check. I further understand that my voluntary consent
to
use my social security account number
is
being requested for purposes of conducting a criminal
background check, pursuant to the authority of the Alabama Community College System Board of
Trustees policy regarding criminal background checks. I understand that neither the Alabama Community
College System nor any employing authority within the Alabama Community College System will deny me
any right, benefit or privilege provided by law because
of
my refusal
to
voluntarily consent
to
the
use
of
my social security account number for the limited purpose of conducting a criminal background check
pursuant to the Alabama Community College System Board of Trustees policy regarding criminal
background checks.
___
I voluntarily consent to the use of my social security account number for the limited
purpose of conducting a criminal background check. Social Security#
______
_
___
I do not consent to the use
of
my social security account number for the limited purpose of
conducting a criminal background check.
___
I consent to the use
of
my driver's license number
to
be
used for the limited purpose of
conducting a review of my driving history.
_ _ I do not consent to the use of my driver's license number for the limited purpose of .
conducting a review
of
my driving history.
1
· (
The information I
ha
ve given
in
my employment application, interviews, and/or relat
ed
resumes
and
documents
is
true, complete, and accurate. ·
I understand
and
agree that if employed, and/or during any period of employment, any false statements,
misrepresentations
of
facts, or omission made by myself become known, my employment sha
ll
be
subject
to immediate termination.
I understand that
in
the event a conviction for a felony or any crime
invo
lving moral turpitu
de
is
found that
the procedures established for the Board
of
Trustees policy concerning criminal background checks will
be fo
ll
owed .
I have read and completely understand this
re
lease.
Applicant's Signature: _ _
_____________
_
Date:
Applicant's Name
(P
lease
print):---------------------
- -
Applicant's
Address:--
-
------------------
- - -
----
Applicant's
Birthday:----------------------
- -
--
-
Applicant's Driver's License Number:
___________________
_ _ _
Applicant's Driver's License State:
-----------------------
Revised March 2019
BISHOP
STATE
COMMUNITY
COLLEGE
FAMILY
RELATIONSHIP
DISCLOSURE
FORM
This form must be completed and returned to the Human Resources Offic
e.
Employee's Name: _
_______________
SSN:
_______
_ _
Job Title/Position:
Employment Date: _
____
___
__
_
Full-Time Part-Time
---
---
Salary Schedule
__
_ _ Rank Step Annual Salary
--- ---
--------
For
purposes
of
this disclosure, relative includes the following: spouse, dependent,
adult
child
and
his
or
her
spouse,
parent,
spouse's
parents,
sibling
and
his
or
her
spouse.
Are
you a relative
of
any
employee
of
the
Alabama
College System, including Bishop State
Community
College,
or
any
member
of
the
State
Board
of
Education?
Yes No
---
---
If
yes, list the name(s), relationship,
and
employer/position
of
relative(s)
I affirm
that
all
information
contained herein
is
correct
to
the
best
of
my knowledge.
Signed:
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------
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Employee
Date
<
BISHOP
STATE
BISHOP STATE
COMMUNITY
COLLEGE
DRUG-FREE WORKPLACE POLICY
This
certifies
that
I have read the following Drug-Free Workplace Policy:
In compliance
with
the drug-free workplace requirements
of
public law 100-690 for recipients
of
Federal
contracts and grants, the following policy
is
in
effect for Bishop State Community College.
1.
The
unlawful manufacture, distribution, dispensation, possession,
or
use
of
a controlled substance
is
prohibited by Bishop State Community College
on
any property owned, leased, or controlled
by
Bishop State Community College or during any activity conducted, sponsored,
or
authorized
by
or
on
behalf
of
Bishop State Community College.
A "controlled substance" shall include any substance defined
as
a controlled substance in
Section 102
of
the
Federal Controlled Substance Act
(21
U.S.
Code
802) or
in
the Alabama
uniform Controlled Substance Act
(Code
of
Alabama, Section 20-2-1, et. seq.).
2.
Bishop State Community College
has
and
shall maintain a drug-free awareness program to inform
employees about
the
following:
a.
The dangers
of
drug abuse in the workplace;
b.
Bishop State Community College's policy
of
maintaining a drug-free workplace.
c.
Any available drug counseling, rehabilitation, and employee assistance program;
and
d.
The
penalties
that
may
be
imposed upon employees for drug abuse violations.
3.
All
employees
of
Bishop State Community College shall comply
with
paragraph 1 above.
4.
Any employee who
is
convicted by any Federal
or
State Court
of
an
offense which constitutes a
violation
of
paragraph 1 above shall notify President Perry Ward
in
writing
of
said conviction within
five
(5)
days
after
the conviction occurs. Conviction,
as
defined in P
.L.
100-690, shall mean "a finding
of
guilt (including a plea
of
nolo contendere) or imposition
of
a sentence, or both."
5.
In
the event
of
a report
of
a conviction pursuant
to
paragraph 4 above where the employee
is
working
in
a project
or
a program funded through a Federal contract
or
grant, Bishop State
Community College shall notify in writing within ten
(10)
days any Federal agency
to
whom
such
notification by Bishop State Community College
is
required under
P.L
. 100-690.
6.
In
the event
an
employee violates paragraph 1 above or receives a conviction
as
described in
paragraph 4 above, the respective employee shall
be
subject to appropriate disciplinary action
which may include,
but
is
not limited to, termination of employment. Bishop State Community
College shall also reserve the right
to
require
sa
id employee,
as
a condition
of
continued
employment,
to
satisfactorily complete a drug treatment or rehabilitation program
of
a reasonable
duration and nature.
7.
Bishop State Community College shall make a good faith effort
to
ensure
that
paragraphs 1-6 above
are followed.
8.
Each
employee
of
Bishop State Community College shall receive a copy
of
this policy.
My
signature below affirms
that
I have read and understand this Drug-Free Workplace Policy.
Employee's Signature
Date
BISHOP
STATE
POLICY 603: HARRASSMENT
Employees shall adhere to the highest ethical standards and professionalism and refrain from any form
of
harassment. Both employees and students shall strive to promote an environment that fosters personal
integrity where the worth and dignity
of
each human being
is
respected. Any practice or behavior that
constitutes harassment shall not be tolerated.
Harassment can be defined as but
is
not limited to:
Disturbing conduct which
is
repetitive;
Thr
eatening
conduct;
Intimidating conduct;
Inappropriate
or
offensive slurs,
jokes,
language, or other verbal, graphic,
or
other
1 ike
conduct
;
Unwelcome sexual advances or requests for sexual favors;
Assault;
Repeated contact solicited during non-traditional business hours which may
be
perceived
as harassment by recipient unless it
is
specifically associated with work related duties.
Employees and students who are found in violation
of
this policy shall be disciplined as deemed
appropriate
by
the investigating authority.
HARASSMENT POLICY ACKNOWLEDGEMENT
I,
the undersigned, hereby acknowledge receipt
of
the College's Harassment Policy as
set
forth
in
the Board
of
Trustees policies and procedures governing the
Alabama Community College System. I also understand that violation
of
this policy may result in disciplinary action
up
to
and including dismissal.
Employee's Signature
Date
BISHOP
STATE
I have received directions on how to access the Bishop State Faculty-Staff Employee
Handbook online. I understand that it
is
my responsibility to read and comply with the
po
licies and procedures contained
in
this handbook and any revisions made to
it.
Employee's Signature
Employee's Name (Print)
Date
BISHOP
STATE
Will
you be able
to
perform
the
essential
job
functions
with
or
without
reasonable accommodations?
Yes
No
--
Signature (Sign)
Date
Printed Signature
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