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East Central University (East Central University)

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File type: PDF

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East Central University
Affirmative Action Office
Ada, OK 74820
Applicant Data Form
NOTE: Submission of this information is VOLUNTARY AND WILL NOT BE USED IN THE CONSIDERATION OF YOUR
APPLICATION. The information is processed by the Affirmative Action Office and is used exclusively as provided by law for
compliance purposes. The individuals participating in the selection process have no access to the information provided on this
form.
Please provide the following information:
Last Name:
First Name:
Middle Initial:
Position applied for:
Where did you hear about the advertised position?
Gender:
Male
Female
Ethnicity/Race:
American Indian or Alaskan Native
Asian or Pacific Islander
Black/African
-
American (not of Hispanic origin)
Hispanic (persons of Spanish culture or origin, regardless of race)
White (not of Hispanic origin)
Citizenship
:
R
Resident Foreign National. An
alien who has been admitted for permanent residence (must have Alien
Registration Card, Form 1
-
151)
N
Non
-
Resident Foreign National. An alien admitted temporarily for specific purposes
and periods of time
,
Indicate visa type
:
C
U. S. Citizen
*
For Veterans Only
:
Do you qualify as a Vietnam Era Veteran?
Yes
No
Any veteran of the armed services who served on active duty for at least 181 days, any p
(
art of which occurred between August 5,
, and May 7, 1975, and was discharged honorably or released sooner because of a service
1964
-
related disability.)
Are you considered a disabled veteran by the U. S. Veterans Administration?
Yes
No
(
Any person entitled to compensation by the Veterans Administration for a disability rated at 30 percent or more, or who was
discharged or released from active duty by reason of service
-
connected disability.)
Do you wish to declare yourself as qualifyi
ng for reasonable accommodations as provided for by the Americans with Disabilities
Act?
Yes
N
o
An Equal Opportunity/Affirmative Action Employer
EAST CENTRAL UNIVERSITY, ADA, OK
Disclosure to Employment Applicant
I hereby authorize East Central University (ECU) to contact any and all corporations, former employers, educational
institutions, law enforcement agencies and military services to release information about my background including, but
not limited to, information about my employment, education, driving record, criminal record and general public records
history to East Central University. I make this authorization in return for ECU’s consideration for me for employment.
I release from liability all persons, companies and schools supplying such information. I indemnify East Central
University against any liability, which may result from making such requests. If I am employed, this release shall remain
in effect for the length of my employment. A copy of this form will serve as authorization to release information
requested.
I believe, to the best of my knowledge, that all information I have provided is accurate, true and correct, and that I fully
understand the terms of this release.
I agree that a copy or fax of this document shall be as valid as the original.
Name (please print):
Other names used (please print):
Address:
City/State/Zip:
*Signature of Applicant: Date:
*This form is incomplete if it is not signed. Any and all incomplete application materials can cause a delay in the
application process. Return this form and all required application materials to the Employment Services Office, via
email (i.e., a scanned copy) to es@ecok.edu, via fax (580)559-5484 (Attn: Ty Anderson, Director), or via ECU’s
mailing address at 1100 E. 14
th
St., Ada, OK, 74820.
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East Central University (East Central University)

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Completed 22 July 2020

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