TA Application
4 /2014
TEACHING ASSOCIATE APPLICATION FOR EMPLOYMENT
California State University, Chico
Office of the Vice Provost for Human
Resources
Chico, California
95929-0024
Voice 530-898-5029 TDD
530-898-5870
Position Title
Department
To comply with the Immigration Reform and Control Act of 1986, all new employees must
provide proof of identity and authorization to work.
Name: Last, First, M.I. -- as it appears on your Social Security Card Previous name(s) used, if different
Mailing Address: Post Office Box or Number and Street City, State, and Zip
( ) ( ) ( )
Home Phone Number Work Phone Number Message Phone Number
EDUCATION
Highest degree received and date of receipt:
Application must be accompanied by transcripts.
Name of School Major Diploma/Degree Earned
Professional Schools or Licenses and Certificates:
Other Educational Information:
WORK AUTHORIZATION
California State University, Chico only employs individuals legally authorized to work in the United States. Should you be offered a position on this
campus would you be able to furnish proof that you are authorized to work?
ˆ
NO
ˆ
YES If 'no,' explain:
The position for which you have applied may require the use of a state vehicle for state business. If you are offered and accept a
position
can you furnish proof of a valid California driver's license? NO
ˆ
YES
ˆ
If 'no",
explain:
TA Application
4 /2014
EMPLOYMENT
HISTORY
Account for work experience during the last 10 years and describe specific duties that are relevant to the position for which you are
applying.
To allow for accurate review and
consideration,
your application should provide a complete and detailed description of your
work
experience. It is to your benefit to be as thorough as possible because this information will be used to determine if you are qualified for
this
position. You may attach an additional page if more space is required or refer to a résumé only for the duties
description.
FROM (mo/yr): TO (mo/yr): JOB TITLE or OCCUPATION: Part time
ˆ
Full time
ˆ
NAME OF YOUR DIRECT SUPERVISOR:
EMPLOYER'S NAME and ADDRESS: SUPERVISOR'S PHONE NUMBER:
(
)
DESCRIPTION OF DUTIES:
REASON FOR LEAVING:
FROM (mo/yr): TO (mo/yr): JOB TITLE or OCCUPATION: Part time
ˆ
Full time
ˆ
NAME OF YOUR DIRECT SUPERVISOR:
EMPLOYER'S NAME and ADDRESS: SUPERVISOR'S PHONE NUMBER:
(
)
DESCRIPTION OF DUTIES:
REASON FOR LEAVING:
FROM (mo/yr): TO (mo/yr): JOB TITLE or OCCUPATION: Part time
ˆ
Full time
ˆ
NAME OF YOUR DIRECT SUPERVISOR:
EMPLOYER'S NAME and ADDRESS: SUPERVISOR'S PHONE NUMBER:
(
)
DESCRIPTION OF DUTIES:
REASON FOR LEAVING:
FROM (mo/yr): TO (mo/yr): JOB TITLE or OCCUPATION: Part time
ˆ
Full time
ˆ
NAME OF YOUR DIRECT SUPERVISOR:
EMPLOYER'S NAME and ADDRESS: SUPERVISOR'S PHONE NUMBER:
(
)
DESCRIPTION OF DUTIES:
REASON FOR LEAVING:
EMPLOYMENT/EDUCATION
INFORMATION RELEASE
AUTHORIZATION
As an applicant for a position with California State University, Chico I do hereby authorize all past and present employers, references, institutions of higher education and
other appropriate persons or agencies to release to the University any and all information regarding my employment/education upon request. I do hereby agree to hold
such employers, institutions, references, persons, etc. harmless from liability for releasing said information.
SIGNATURE must be original DATE
APPLICANT
CERTIFICATION
I certify that the answers I have given in the materials I have submitted in application for this position are true and correct and that I have not knowingly withheld
any facts or circumstances. I understand that all answers given in my application for employment are subject to verification and that should I be employed at the
campus, any misrepresentation or omission of facts in this application may be sufficient reason for dismissal. The application materials include this document
and any other materials submitted.
SIGNATURE must be original DATE