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CCCApplication CCC Application

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__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Application for
Employment
PART A
Clovis Community College is committed to the policy of providing Equal Employment Opportunity to
all of its employees and applicants for employment regardless of race, age, religion, color, national
origin, ancestry, sex, sexual orientation, spousal affiliation, gender identity, veteran status, physical or
mental disability, or serious medical condition. The College will endeavor to maintain the
confidentiality of the information contained in this application to the extent permitted by Law.
Personal Data
Position Applying For_________________________________________________________________
Date Available for Employment ________________________________________________________
Name (First, Middle, Last) _____________________________________________________________
List any former name(s) which may appear on educational and prior employment records:
Present Address (Street, City, State) _____________________________________________________
Are you 18 years of age or older?
Yes No
Do you have the ability to obtain a valid driver’s license? (Answer only if operating a motor vehicle is
a requirement of the job for which you are applying.)
Yes No
Do you have the right to work in the United States
Yes No
without sponsorship?
Are you subject to any post-termination agreements with a
Yes No
Prior employer? If yes, please explain ___________________________________________________
Permanent Address (if different) ________________________________________________________
Home Phone/Mobile
_________________________________________________________________
Email Address
__________________________________________________
___________________
_
Reset Form
__________________________________________________________________________________
__________________________________________________________________________________
Name of employer: ________________________________________________________________
Address:_________________________________________________________________________
City/State, Zip: ____________________________________ Phone Number _________________
Job title and nature of work done: ____________________________________________________
Dates of employment: From:______________ To:______________ Rate of Pay: ___________
Number of hours per week:_______________ May we contact employer? ____________
Reason for leaving or wanting to leave/additional comments: ______________________________
_______________________________________________________________________________
_______________________________________________________________________________
Name of employer: ________________________________________________________________
Address:_________________________________________________________________________
City/State, Zip: ____________________________________ Phone Number:_________________
Job title and nature of work done: ____________________________________________________
Dates of employment: From:______________ To:______________ Rate of Pay: ___________
Number of hours per week:_______________ May we contact employer? ____________
Reason for leaving or wanting to leave/additional comments: ______________________________
_______________________________________________________________________________
_______________________________________________________________________________
Name of employer: ________________________________________________________________
Address:_________________________________________________________________________
City/State, Zip:__________________________________ Phone Number: ___________________
Job title and nature of work done: ____________________________________________________
Dates of employment: From:______________ To:______________ Rate of Pay: ___________
Number of hours per week:_______________ May we contact employer? ____________
Reason for leaving or wanting to leave/additional comments: ______________________________
_______________________________________________________________________________
_______________________________________________________________________________
Have you previously worked for Clovis Community College? Yes No
Department/Area:__________________________ Supervisor’s Name:________________________
Please list names of all relatives currently employed at Clovis Community College.
Work Experience
Begin with your most recent experience. Do not indicate "See Resume".
Please explain any gaps in employment history:________________________________________
______________________________________________________________________________
References
Please provide the name and phone number of three work-related references.
Education
Do you have a high school diploma? Yes No
Do you have a GED certificate?
Yes No
Do you have an associate degree?
Yes No
Do you have a bachelor’s degree?
Yes No
Do you have a master’s degree?
Yes No
Do you have a doctorate?
Yes No
Please list your field of study or major courses and the name of the institution where the degrees were
obtained.
Summarize Your Special Skills or Qualifications
Include specific achievements, certifications, licenses, computer skills, or other job-related skills.
Additional Information
Please give any additional information that more fully describes your interests and qualifications. (Use additional
sheets of paper if necessary.)
IMPORTANT: All transcripts and records from high schools, colleges, or universities received by Clovis
Community College will become the property of the institution. No transcripts will be released. Applicants who
desire copies of their transcripts should write directly to the institutions attended.
Federal and state agencies r
equire public disclosure of specific institutional policies. The policies listed below are
on file in the CCC library for public inspection:
Discrimination Policies and Grievance Procedures Attendance, Costs, and Refund Policy
Privacy of Student Records Graduation and Completion Rates
Campus Crime/ Campus Sex Offenses Americans With Disabilities
Drug-Free Workplace/Drug Free Campus
Reference Check Policy
In order to ensure the most qualified person possible is hired, the information furnished on this application
form is considered to be only one step in the hiring process. Background and past performance inquiries
may be conducted. The Disclosure Notice and Authorization Regarding Background Consumer Reports
(Part B) form must be completed.
Name Company Phone Number Email Address
Dear Applicant:
Thank you for your interest in an employment opportunity at Clovis Community College. The College is
a public employer and is required to comply with certain federal and state laws. According to the
Inspection of Public Records (Section 14-2-1, New Mexico Statutes Annotated, 1978) every citizen of
this state has the right to inspect any public records of the state. Therefore, your intent for employment
with the College may become a matter of public record if outside inquiries and/or interview arrangements
are made.
Clovis Community College has a Policy On Confidentiality For Personnel Recruitment which is available
upon request.
To assure that the College remains a responsible state entity, and to protect your constitutional rights of
privacy, the Human Resource Services Office must inform you, in writing, about this policy. This will
give you the opportunity to determine if your application will be made a part of the public records file.
As a part of your application, Clovis Community College asks you to review and check one of the items
below and return this letter to:
Human Resource Services Office
417 Schepps Blvd.
Clovis, NM 88101
(575) 769-4033
I hereby give Clovis Community College permission to release my records for
public inspection should I be selected as a candidate for whom outside inquiries
and/or interview arrangements are made.
I do not give Clovis Community College permission to release my records for
public inspection knowing that this will disqualify me from consideration.
Position Applying for _____________________________________________________
Applicant’s Signature _____________________________________________________
Applicant’s Name ________________________________________________________
Date ___________________________________________________________________
(please type or print)
click to sign
signature
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DISCLOSURE NOTICE AND AUTHORIZATION REGARDING
BACKGROUND CONSUMER REPORTS
Important: Please read carefully before signing.
PART B
Please return this form to the Clovis Community College Human Resource Services
Office. It should not, however, be attached to your application.
DISCLOSURE
A consumer report and/or investigative consumer report including information concerning your
character, employment history, general reputation, personal characteristics, police record,
criminal records, education, qualifications and/or credit and indebtedness may be obtained in
connection with your application for and/or continued employment with the employer. These
reports may include experience information along with reasons for termination of past
employment. Further, understand that information from various Federal, State, local and other
agencies which contain your past activities may be requested at any time during the application
process or during your employment with the company.
The name, address and telephone number of the Company preparing the report is: First
Advantage P.O. Box 3367 Seminole, FL 33775-3367; Toll free number: 1-800-321-4473
ext. 8. Their privacy Policy can be reviewed at http:// www.fadv.com/privacy-policy.
Please be advised that you have a right to inspect the files that the Consumer Reporting
Agency may have on you during normal business hours and upon you furnishing proper
identification.
AUTHORIZATION
This application is only valid for the position applied for as listed on page 1. I understand that
my status as an applicant will end at the close of this job search. I understand that if the hiring
department feels the applicant pool is inadequate, the search may be extended or suspended. I
understand that I may apply for employment in the future by completing a new application for
any vacant position. I understand that if an employee is terminated for cause, released under
the probationary period, or resigned after disciplinary actions, the employee will not be
eligible for future employment with Clovis Community College in any capacity. I certify that
previous employment with CCC did not end under the circumstances mentioned above.
By signing below, you hereby authorize without reservation, any party or agency contacted
by this employer to furnish the above mentioned information. You further authorize ongoing
procurement of the above mentioned reports at any time during your employment (or
contract). You also agree that a fax or photocopy of this authorization with your signature be
accepted with the same authority as the original.
You hereby authorize and request, without any reservation, any present or former employer,
school, police department, financial institution, division of motor vehicles, consumer
reporting agencies, or other persons or agencies having knowledge about you to furnish First
Advantage with any and all background information in their possession regarding you, in
order that your employment qualifications may be evaluated.
The following is for identification purposes
only
to perform the background check:
Position applying For:____________________________________________________________
Address:_______________________________________________________________________
City:_______________________________ State: __________________ Zip: _______________
Social Security Number:___________________ Date of Birth (MM/DD/YYYY):____________
Other Former Name(s):___________________________________________________________
Signature:_________________________________________Date:_________________________
Print Your Name:________________________________________________________________
click to sign
signature
click to edit
B. Is there an accommodation that the college can make to assist you? __________________
________________________________________________________________________
__
______________________________________________________________________
Equal Employment Program
PART C
Voluntary Information Survey
Clovis Community College invites all applicants to submit information pertaining to any areas in which you might
be considered a minority. The information is necessary in order to facilitate the college’s equal employment efforts.
This information will not affect your employment and will not be available for use in the selection process. It will be
used by the Human Resource Services office to compile statistics and will be kept confidential.
Date: ______________
Position Applying For: ___________________________________________________________________
Gender:
_____Male _____Female
Ethnicity:
_____Hispanic or Latino
_____American Indian or Alaskan Native
Veteran Status:
Disabled Veteran
Active Wartime or Campaign Badge Veteran
Protected Veteran
Disability Status:
A. Do you consider yourself, or are you considered
by others to be disabled?
_____Yes _____No
HOW DID YOU LEARN OF THIS VACANCY:
Friend/Relative, Name:_____________________________________________________________
Newspaper Ad, Name:______________________________________________________________
Professional Journal, Name:_________________________________________________________
College, Name:____________________________________________________________________
Internet: _________________________________________________________________________
Other, Please describe: _____________________________________________________________
CCC Website: ____________________________________________________________________
Please return this form to the Clovis Community College Human Resource Services Office.
DO NOT ATTACH TO YOUR APPLICATION.
_____Not Hispanic or Latino
Race:
_____Black or African American
_____Native Hawaiian or Other Pacific Islander _____Unknown/No Response
_____White
_____Asian
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CCCApplication CCC Application

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Completed 5 November 2019

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