(rev 2018)
EMPLOYMENT APPLICATION
Bladen Community College
7418 NC HWY 41 WEST PO BOX 266 DUBLIN, NORTH CAROLINA 28332
PHONE (910 )879-5500 FAX (910) 879-5564 website http://www.bladen.cc.nc.us DATE:
SPECIFIC TITLE OF
POSITION APPLIED FOR: _____ ___________________
(A SEPARATE APPLICATION FORM MUST BE COMPLETED FOR EACH POSITION FOR WHICH YOU ARE APPLYING.)
Are you available to work
FULL-TIME PART-TIME 10 MONTHS Adjunct
(for teaching positions only)
2. PERSONAL DATA
NAME: : :
LAST FIRST MIDDLE
PREFERRED NAME :__________________________________________ EMAIL ADDRESS :_____________________________________________________
ADDRESS: : : :
STREET NUMBER OR PO BOX CITY STATE ZIP
TELEPHONE: HOME (include area code): WORK (include area code):
HAVE YOU EVER BEEN CONVICTED OF AN OFFENSE AGAINST THE LAW OTHER THAN A MINOR TRAFFIC VIOLATION?
(If yes, explain fully on an additional sheet.) (A conviction does not mean you cannot be hired. The offense and
YES NO how recently you were convicted will be evaluated in relation to the job for which you are applying.)
Have you filled out an application here before? YES NO Have you worked here before? YES NO
WHEN: POSITION: WHEN: POSITION:
Are you legally eligible to work in the United states? YES NO Are you at least 18 years of age? YES NO
List names and relationships of any family members who work here.
Name:__________________________________________________________ Relationship:______________________________________________
Name:__________________________________________________________ Relationship:______________________________________________
3. EDUCATION
A copy of transcripts, licensure or certification as applicable is required before this application can be processed.
Circle Highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED College 1 2 3 4 Graduate School 1 2 3 4
Schools
Name and Location
Graduate
Major/Minor
Course Work
Type of
Degree Received
DO NOT
COMPLETE
C.L.S
High School
Yes
No
Technical
School/College
Yes
No
College(s)
University(ies)
Yes
No
Graduate or
Professional
Yes
No
Other
Education
Yes
No
(rev 2018)
Licenses and Certifications. Give dates and sources of issuance.:
4. EMPLOYMENT EXPERIENCE A resume may not be used as a substitute but may be attached.
For each position, indicate number of people you supervised if any and type of supervision (ex. Line, functional, technical). In listing prior work experience,
include military and volunteer service. Use additional paper if more space is needed.
Present or Last Employer : Job Title:
Employer’s Address : Supervisor: Telephone:
Dates Worked From: to: Full-time :
month / year month / year Total Number Years / Months
Starting Salary : Ending Salary : Part-time :
Total Number Years / Months
Duties: :
Number of hours per week
Reason for Leaving:
If currently working here, may we contact this employer for a reference? YES NO
Next Employer: Job Title:
Employer’s Address: Supervisor: Telephone:
Dates Worked From: to: Full-time :
month / year month / year Total Number Years / Months
Starting Salary Ending Salary Part-time :
Total Number Years / Months
Duties: :
Number of hours per week
Reason for Leaving:
Next Employer: Job Title:
Employer’s Address: Supervisor: Telephone:
Dates Worked From: to : Full-time :
month / year month / year Total Number Years / Months
Starting Salary : Ending Salary : Part-time :
Total Number Years / Months
Duties: :
Number of hours per week
Reason for Leaving:
(rev 2018)
Next Employer: Job Title:
Employer’s Address: Supervisor: Telephone:
Dates Worked From: to : Full-time :
month / year month / year Total Number Years / Months
Starting Salary : Ending Salary : Part-time :
Total Number Years / Months
Duties: :
Number of hours per week
Reason for Leaving:
Next Employer: Job Title:
Employer’s Address: Supervisor: Telephone:
Dates Worked From: to : Full-time :
month / year month / year Total Number Years / Months
Starting Salary : Ending Salary : Part-time :
Total Number Years / Months
Duties: :
Number of hours per week
Reason for Leaving:
Next Employer: Job Title:
Employer’s Address: Supervisor: Telephone:
Dates Worked From: to : Full-time :
month / year month / year Total Number Years / Months
Starting Salary : Ending Salary : Part-time :
Total Number Years / Months
Duties: :
Number of hours per week
Reason for Leaving:
Have you ever been dismissed or forced to resign from a prior job? YES NO If yes, explain in detail (Use an
additional sheet of paper if necessary) :
(rev 2018)
5. OTHER QUALIFICATIONS AND TRAINING
Describe other special qualifications; skills with tools, machines, and equipment; and courses, workshops, or other training relative to the position for which you
are applying. :
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Bladen Community College does not pay for interview travel costs and/or relocation.
Applicants for faculty positions who accept an interview will be asked to demonstrate proficiency in oral and written communications in the language in which the
assigned courses will be taught.
Applicants for positions which require a specific degree, certification, or license will be required to have official transcripts or documentation on file with the
College prior to their hire date.
Security checks are required for all applicants who accept regular employment and for applicants who accept certain part-time employment.
Proof of citizenship or immigration status will be required of all applicants upon employment.
A SEPARATE APPLICATION IS REQUIRED FOR EACH POSITION FOR WHICH YOU APPLY
AGREEMENT
By signing my name below, I (1) certify that all statements made by me on this application are true and complete to the best of my knowledge
and that I understand that misrepresentations or omissions may be cause for rejection or may be cause for subsequent dismissal if I am hired,
and (2) understand that nothing contained in this application or in the interview process is intended to create an employment contract between
the college and me, and (3) authorize the college to contact and obtain information from all references, employers, public agencies and others
to verify the accuracy of all information provided in this application. I hereby waive all rights and claims I may have regarding the college for
seeking, obtaining, and using truthful information in the employment process and all other persons, corporations, or organizations for furnishing
such information about me. If this application results in my employment, I understand I have a right to terminate my employment at any time
and for any reason and the college retains a similar right, not withstanding any contractual agreement between the employee and the college. I
understand this entire statement applies to the period prior to or after I may be employed.
: :
SIGNATURE DATE
Bladen Community College is an affirmative action/equal opportunity employer, making selections on the basis of knowledge,
skills and abilities without regard to race, color, religion, national origin, sex, age or disability.
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signature
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(rev 2018)
Background Investigation
I, :___________________________, do hereby grant by signature below, Bladen Community College the authority to
conduct a Criminal Background Investigation for purpose of employment. I am providing the identifying information
as listed in this authorization to conduct this investigation.
Name:______________________________________________________________________________________________
Address:____________________________________________________________________________________________
Social Security Number:_____________________________________ Date of Birth:_____________________________
Signature:_________________________________________________ Date:____________________________________
Please List Three Professional References
Name:______________________________________________________________________________________________
Address:____________________________________________________________________________________________
Email:_______________________________Telephone:_____________________________Fax:______________________
Name:______________________________________________________________________________________________
Address:____________________________________________________________________________________________
Email:_______________________________Telephone:_____________________________Fax:______________________
Name:______________________________________________________________________________________________
Address:____________________________________________________________________________________________
Email:_______________________________Telephone:_____________________________Fax:______________________
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signature
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(rev 2018)
EQUAL OPPORTUNITY INFORMATION
The information requested below is to help us determine how well our recruiting efforts are reaching all segments of the population.
It will in no way affect you as an applicant. SUBMISSION IS VOLUNTARY.
DATE OF BIRTH:_____________________________________
Month Day Year
SEX Male Female
ETHNIC GROUP
White (Caucasian, non-Hispanic)
African-American
American Indian (including Alaskan native)
Hispanic (Mexican, Puerto Rican, Cuban, Central or
South American, other Spanish origin regardless of race)
Asian (including Pacific Islander)
DISABILITY A disability is any impairment which substantially
limits a major life function. This information is optional. Failure to
provide it will not subject you to any adverse treatment. It will be
maintained confidentially.
Visual impairment/ Blindness
Hearing impairment/ Deafness
Cardiovascular disorder
Emotional/ Mental disorder
Nervous System/ neurological disorder (ex. Epilepsy)
Respiratory impairment
Loss or impairment of upper or lower limbs
Disabling diseases (arthritis, diabetes, etc.)
Other (explain) ______________________________
Please indicate your referral source:
Job Posting/Employee at BCC Newspaper Name:_____________________________________
NC Employment Security Commission Internet Which site:____________________________________
Job Posting at other College/University Other:________________________________________________
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