Alabama Community College System
Application No.
APPLICATION FOR EMPLOYMENT
Shelton State Community College
College
Position
Information
Title of position for which you are applying:
Date of Application
Personal
Information
Last Name
First Name
Middle Initial
Address
City
State
Zip
Phone: Home
Work
Cell
E-mail Address
Secondary and
Postsecondary Education
School/College
Dates Attended
From / To
Major
Minor
Degree(s)
Earned
High
School/
GED
College
College
College
Other
(Specify)
Additional
infromation
Community College System college.
Yes No
If yes, list the name of the college(s) and dates:____________________________________________________
Employment History
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary(optional)
Reason for Leaving
Employment History
(Continued)
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary (optional)
Reason for Leaving
Employment History
(Continued)
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary (optional)
Reason for Leaving
Employment History
(Continued)
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary (optional)
Reason for Leaving
Employment History
(Continued)
Employer
Telephone Number
Job Duties
Address
Dates of Employment
Title
Full-time
Part-time
Hr. Rate/Salary (optional)
Reason for Leaving
May we contact your current employer? Yes No
Skills, Awards,
Certificates or
Professional
Activities
Note: Please provide details of each. May use a separate sheet if necessary.
References
Please list three references, other than relatives, who can provide information verifying qualifications,
character, or work experience.
Name and Title
Address
Phone Number
Family
Relationship
For the purposes of discl
osure, relative includes any person related within the fourth degree of affinity
or consanguinity to any job, position, or office of profit with state or with any of its agencies.
Are you a relative of any employee in the Alabama Community College system, including Shelton State, or any
member of the Alabama Community College System Board of Trustee Yes No
If yes, list the name(s), relationship, and employer/position of relative(s):
Felony
Conviction(s)
Have you ever been convicted of or pled no contest or guilty to any felony or any crime involving theft,
dishonesty, violence, or sexual misconduct? Yes No
If yes, explain below:
Consent Agreement
I represent and warrant that the information I have given on this application is full and true to the best of my knowledge and
belief. I further acknowledge that I understand that I must provide documented verification of education, experience, and
required certifications and/or l
icensures. And further, I represent and warrant that I have answered fully and truthfully all
questions regarding criminal convictions/records.
I understand that any offer of employment is contingent upon a
satisfactory criminal background investigation and I hereby authorize my employing authority within the Alabama
Community College System and/or its assigns to conduct a criminal background history investigation. I understand
that in the event a conviction for a felony or any crime involving moral turpitude is found that the procedures
established for the Board of Trustees policy concerning criminal background checks will be followed. I further
understand that I will be responsible for the cost of said criminal background check. I hereby expressly request, and
give permission to, former employers and any persons who may have pertinent information concerning this application to
furnish such information to college officials. I agree to hold such persons harmless, and I do hereby release them from any
and a
ll liability for damage of any nature whatsoever for furnishing such information. I understand that failure to provide full
and true information on this application may result in disqualification or dismissal.
Signature of Applicant
Date
Are you a member of the Alabama Community College System Applicant Pool?
Yes
No
Shelton State Community College
Attention: Office of Human Resources
9500 Old Greensboro Road
Tuscaloosa, AL 35405
205.391.2272
It is the policy of the Alabama Community College System, including all postsecondary community and technical colleges under the control
of the Alabama Community College System Board of Trustees, that no employee or applicant for employment or promotion, on the basis of
any impermissible criterion or characteristic including, without limitation, race, color, national origin, religion, marital status, disability, sex,
age, or any other protected class as defined by federal and state law, shall be excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program, activity, or employment. (Each institution will make reasonable accommodations for
qualified disabled applicants or employees.)
Revised 11.7.2019
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