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COLBY COMMUNITY COLLEGE (Colby Community College)

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EMPLOYMENT APPLICATION
1255 S. Range • Colby, KS 67701 • Phone: 785-462-3984 • Fax: 785-460-4699
Please complete application in full and answer all questions completely. Type or print legibly. Indicate N/A if not
applicable. Do not indicate “See Resume.” A resume may be attached to provide additional supporting information.
Incomplete applications may not be given consideration for employment. A separate application is required for each
position. Copies are acceptable. If position qualifications include a postsecondary education requirement, college
transcripts are required. Unofficial copies may be submitted initially, but official copies must be received before an
employment recommendation can be made.
Personal Information
Date:______________
Last Name First Name
Middle Initial
Number and Street Address City
State
Zip Code
Cell/Mobile
Telephone Number: Home
Position for which you are applying:
Have you ever been convicted of a felony? If yes, please explain:
(A felony conviction will not necessarily disqualify you for this position.)
Where did you hear about this job?
Military Service
YES
NO
YES
NO
Have you ever been involuntarily terminated from any previous position? If yes, please explain:
Branch of service
If required by this position, do you have a valid driver’s license?
YES
NO
Education
High School diploma/GED:
YES
NO
YES
NO
If no, indicate highest grade completed:
Names and locations of educational institutions attended (list most recent education rst)
Major
Minor
Degree or number of
credits earned
Are you related to any current employees of Colby Community College?
YES
NO
If yes, provide name and relationship: _______________________________________________________________
-1-
COLBY COMMUNITY COLLEGE
Employment
Teaching Summary - complete only if applying for an instructional position.
Summarize your teaching experience below.
(Provide complete details in the “Employment History” Section)
Begin with most recent experience rst and include full-time teaching, part-time teaching, internship, assistantship, etc.
1.
Educational
Institution
State
Courses Taught
Full-time
or Part-time
Dates of
Employment
Employment History
Provide complete information for all employment, including teaching assignments listed above. Begin with present or
most recent employment. Attach additional employment history if necessary. Use supplemental sheets if necessary.
2.
Reason for leaving: ___________________________________________________________________________
Position:
From
To
Immediate Supervisor
Current/Final Salary
Employer Name:
Address and Phone:
Street
City
State Zip
Phone
Full-time or
Part-time Duties: __________________________________________________________
Position:
From
To
Immediate Supervisor
Current/Final Salary
Employer Name:
Address and Phone:
Street
City
State Zip
Phone
Full-time or
Part-time Duties: __________________________________________________________
Position:
From
To
Immediate Supervisor
Current/Final Salary
Employer Name:
Address and Phone:
Street City
State Zip
Phone
Full-time or
Part-time Duties: __________________________________________________________
Reason for leaving: ___________________________________________________________________________
Reason for leaving: ___________________________________________________________________________
-2-
Position:
From
To
Immediate Supervisor
Current/Final Salary
Employer Name:
Address and Phone:
Street
City
State Zip
Phone
Full-time or
Part-time Duties: __________________________________________________________
Position:
From
To
Immediate Supervisor
Current/Final Salary
Employer Name:
Address and Phone:
Street
City
State Zip
Phone
Full-time or
Part-time Duties: __________________________________________________________
Position:
From
To
Immediate Supervisor
Current/Final Salary
Employer Name:
Address and Phone:
Street
City
State Zip
Phone
Full-time or
Part-time Duties: __________________________________________________________
Position:
From
To
Immediate Supervisor
Current/Final Salary
Employer Name:
Address and Phone:
Street
City
State Zip
Phone
Full-time or
Part-time Duties: __________________________________________________________
Please explain any breaks or periods of unemployment in your employment history:
From: ______________ To: ____________________Reason: ____________________________________________
From: ______________ To: ____________________Reason: ____________________________________________
From: ______________ To: ____________________Reason: ____________________________________________
Reason for leaving: ___________________________________________________________________________
Reason for leaving: ___________________________________________________________________________
Reason for leaving: ___________________________________________________________________________
-3-
Reason for leaving: ___________________________________________________________________________
References
Current supervisor: May we contact your current supervisor?
YES
NO
1.
Name
Organization
Address
Title
Phone
City State
Zip
Other professional references (do not include immediate supervisors listed in employment section):
2.
Name
Organization
Address
Title
Phone
City State
Zip
Name
Organization
Address
Title
Phone
City State
Zip
Name
Organization
Address
Title
Phone
City State
Zip
Name
Organization
Address
Title
Phone
City
State
Zip
Name
Organization
Address
Title
Phone
City State
Zip
The College may contact references other than those listed above. Information provided on this application will become
part of your permanent personnel record if you are employed by the college. Materials submitted for consideration as part
of an application for employment are not returnable. A resume or other appropriate materials may be included with the
application but may not be submitted instead of this application. If employed, the College will require certied transcripts
for any college-level education stated on this application as a condition for employment. Unofcial copies of transcripts
are welcome and encouraged with this application.
-4-
Please Read Carefully and Sign Below
I certify that the information provided by me in this application is true and complete to the best
of my knowledge. I understand that any misrepresentation or omission may be grounds for
rejection of my application for current and future employment or for termination, if I have been
employed.
I acknowledge that it is the responsibility of the College to hire qualied applicants, and that it
is the responsibility of the College to make inquiries as the College, in its discretion, deems rel-
evant to assess work performance. I authorize the College, or its agents, to contact references,
to investigate my background, and to make such other inquiries as the College deems relevant to
assess my qualications for the position for which I am applying. I release all parties from any
liability for such disclosure and I understand that the information disclosed will not be released
to me.
I understand that nothing in this application is intended to create an employment contract and
that a job offer is not nal until authorized by the President of Colby Community College and
by the Board of Trustees.
___________________________________________ _____________________
Applicant signature Date
RETURN APPLICATION TO:
Colby Community College
Attn: Human Resources
1255 S. Range Avenue
Colby, KS 67701
CCC is an Equal Opportunity Employer committed to diversifying its work force.
Colby Community College provides equality of opportunity to its applicants for
admission, enrolled students, graduates, and employees. The College does not
discriminate with respect to hiring, continuation of employment, promotion, tenure,
other employment practices, application for admission or career services and
placement on the basis of race, color, gender, age, disability, national origin or
ancestry, sexual orientation, or religion. For inquiries regarding non-discrimination
policies,
contact the Title IX and Section 504 ADA Coordinator, Colby Community
College, 1255 S. Range Ave., Colby, KS 67701 (785.460.5490).
-5-
Challenge students to adapt to a diverse society.
Create opportunities for student growth.
Connect student learning with professional experiences.
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COLBY COMMUNITY COLLEGE
APPLICANT CONFIDENTIAL INFORMATION
Not for interview purposes. To be led separately from application materials.
Applicants are considered for employment and employees are treated without regard to race, color,
religion, sex, national origin, age, marital or veteran status, medical condition or disability.
As employers, we comply with government regulations and afrmative action responsibilities.
Solely to help us comply with government record keeping, reporting and other legal requirements,
please ll out the Applicant Condential Information Form. We appreciate your cooperation. This
data is for periodic government reporting and will be kept in a condential le separate from the
DATE: ___________________________
(PLEASE PRINT)
Position(s) applied for: ___________________________________________________________
Referral Source:
Advertisement
Friend
Relative
Walk-in Employment
Agency
Other
CCC Employee
NAME: _________________________________________PHONE: ______________________
Last
First
Mid-
ADDRESS: ___________________________________________________________________
City
State
Zip
AFFIRMATIVE ACTION SURVEY
Government agencies require periodic reports on the sex, ethnicity, handicapped and veteran status
of applicants. This data is for analysis and afrmative action only. Submission of information about
a disability is voluntary.
Check one:
Female
Male
Race/Ethnic Group:
Check one of the following:
African American
White (not of Hispanic origin)
American Indian/Alaskan Native
Asian/Pacic Islander
Hispanic
Other (please specify)______________
Disabled:
Yes
No
Veteran (any era):
Yes
No
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COLBY COMMUNITY COLLEGE (Colby Community College)

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Completed 25 July 2020

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