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Clark State Community College is committed to assuring (Clark State Community College)

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INSTRUCTIONS
Applicants must furnish complete and accurate information. Even when submitting a resume, this Application must also be fully
completed. In responding to questions on this Application, you may attach an additional sheet(s) of paper should the space provided
not allow adequate space for your information. If you cannot respond to an item, please include an explanation for not responding.
Incomplete applications will not be considered for employment.
GENERAL INFORMATION INTERNAL APPLICANT EXTERNAL APPLICANT
Name: Application Date:
Last First Middle
Address:
Street City State Zip
Phone: Home ( ) Work ( ) Cell ( )
E- mail Address:
For which position(s) are you applying?
Are you over 18 years of age? Yes No If “No,” state age:
(If “No,” your employment is subject to verification that you are of legal age to work.)
Are you legally eligible to work in the United States? Yes No
How did you learn about this opening?
Newspaper (please specify): Springfield/Dayton Daily Columbus Dispatch
Online (please specify site): Career Builder Chronicle Clark State website
Dice Diverse Higher Ed Jobs
Indeed Monster ODJFS
Friend
Springfield C o C
Journal of Blacks i
n
Hi
gher Education
Journal of Blacks i
n
Higher Education
Central State Univ.
Career Services
Women in
Higher Ed
Wright State Univ.
Career Services
Other (please specify):
HR 7/18
Clark State Community College is committed to assuring equal opportunity to all persons and does not discriminate on the basis of
race, color, sex, gender, ethnicity, religion, national origin, sexual orientation, ancestry, age, marital status, veteran status,
socio-economic status, or physical or mental disability and any other protected group status as defined by law or College policy in
its educational programs, activities, admissions, or employment practices as required by Title IX of the Educational Amendments
of 1972, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act and other applicable statutes.
Minorities are encouraged to apply.
Clark State Community College Application for Employment
2
HR 7/18
Are you available for: Full-time Part-time Date available to start:
Have you ever, or do you currently work for Clark State? Yes No If “Yes,” when?
Which dept.? Position title? Supervisor?
Do you have any relatives currently employed with Clark State? Yes No
If Yes, who? Relationship?
MILITARY SERVICE INFORMATION
Are/were you in the U.S. Armed Forces? Yes No
Branch:
Length of service: From: to: Rank at discharge:
Describe any special job related training received relating to position applied for:
EDUCATION
High School: Address:
City: State: Zip:
Did you graduate? Yes No If no, have you received your GED? Yes No
College/University: Address:
City: State: Zip:
Major: Dates attended:
Did you graduate? Yes No Degree received:
Graduate, Trade, Business, or Correspondence School:
Address: City: State: Zip:
Major: Dates attended:
Did you graduate? Yes No Degree/certification received:
Are you currently enrolled in school? Yes No Indicate years of experience with computers:
List software that you have working knowledge of:
Clark State Community College Application for Employment
3
HR 7/18
EMPLOYMENT HISTORY
Starting with your present or last job, account for all periods of time, unemployment and military service included. (All
applicants must account for the last ten years.) Even if you mark “no” and indicate you prefer we not contact your current
employer at this time, your current or most recent employer may be contacted after a job offer has been made and
accepted.
1.) Current or Most Recent Employer:
Address: City: State: Zip:
Phone: ( ) Supervisor’s name:
Position held: Full-Time Part-Time
Job duties and responsibilities:
Employed from: to: Start pay: hr./yr. Final pay: hr./yr.
Reason for leaving:
May we contact this employer? Yes No If “No,” please explain:
2.) Employer:
Address: City: State: Zip:
Phone: ( ) Supervisor’s name:
Position held: Full-Time Part-Time
Job duties and responsibilities:
Employed from: to: Start pay: hr./yr. Final pay: hr./yr.
Reason for leaving:
May we contact this employer? Yes No If “No,” please explain:
Clark State Community College Application for Employment
4
HR 7/18
Yes
3.) Employer:
Address: City: State: Zip:
Phone: ( ) Supervisor’s name:
Position held: Full-Time Part-Time
Job duties and responsibilities:
Employed from: to: Start pay: hr/yr Final pay: hr/yr
Reason for leaving:
May we contact this employer? Yes No If “No,” please explain:
Have you ever been discharged? No If “Yes,” please explain:
Summarize your skills and experience that qualify you for the position(s) you are seeking:
REFERENCES
Please list three professional references (No relatives please)
1.) Name: Association:
Address: City: State: Zip:
Phone: Home ( ) Work ( ) Years acquainted:
2.) Name: Association:
Address: City: State: Zip:
Phone: Home ( ) Work ( ) Years acquainted:
3.) Name: Association:
Address: City: State: Zip:
Phone: Home ( ) Work ( ) Years acquainted:
Clark State Community College Application for Employment
5
HR 7/18
CONDITIONS OF EMPLOYMENT AT CLARK STATE COMMUNITY COLLEGE
I, , hereby affirm that the information provided in this
Application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also understand that
falsified information, significant omissions, or misrepresentations may disqualify me and may be considered sufficient
justification for dismissal if discovered at a later date. When I responded to questions on this Application, I continued on
a separate sheet of paper and attached it to this Application when I required more space to fully answer all questions.
I authorize a thorough employment background investigation and agree to cooperate in such investigations. I agree to
release, from all liabilities or responsibilities, all persons, agencies, and corporations requesting or supplying such
information. If employed, I release Clark State Community College from any liability for future references it may provide
regarding my work history at the firm.
I understand that if employed, I will receive a letter of employment containing conditions of employment and will pledge
to preserve in strictest confidence any sensitive information concerning Clark State Community College and/or their
stakeholders, which comes to my knowledge through my position. I understand that nothing contained in this employment
application or in the granting of any interview is intended to create an employment contract between Clark State
Community College and myself for either employment or for the providing of any benefit. No promises regarding
employment have been made to me and I understand that no such promise is binding upon Clark State Community College
unless made in writing by the President or the Director of Human Resources of Clark State Community College. If an
employment relationship is established, I understand that the relationship will be “Employment at will” and I have the
right to terminate my employment at any time with or without notice, and Clark State Community College retains a similar
right.
I agree that any inventions, publications, and/or patents, etc., that I produce, develop, or create while working as a Clark
State Community College employee and using Clark State Community College resources become the sole property of Clark
State Community College.
Signature Date
By checking this box, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.
Visit us online at www.clarkstate.edu | Email us at jobs@clarkstate.edu | 937.328.6090
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Completed 9 October 2020

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