Fillable Employment-application EMPLOYMENT APPLICATION

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Employment-application EMPLOYMENT APPLICATION

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Office of Human Resources
(316) 323-6898 or 218-6898 toll-free from the Wichita/metro area
901 S. Haverhill Road El Dorado, KS 67042 (316) 321-2222
EMPLOYMENT APPLICATION
To be considered for employment, you are required to complete an application form. The offer of employment is contingent upon the abilit y to provide
documentation which demonstrates employment eligibility required by the Immigration Reform and Control Act of 1986. All new employees will be required to
complete an “Employment Eligibility Veri fication” ( Form I-9 ) and produce requested documentation after employment. *Federal law requires to Butler
Community College to hire only United State citizens and aliens authorized to work in the United States.
Please answer completely and sign the application form.
PERSONAL INFORMATION
Full Name__________________________________________________________________________________________________________
Last First Middle
Address____________________________________________________________________________________________________________
Street/PO Box City State Zip
Telephone No. Home ( )_____________________________________ Work ( )_____________________________________________
List other names under which employment or academic records have been filed.
1 .)_________________________________________________2.)______________________________________________________
POSITION INFORMATION
Position(s) for which you are applying: Available Date: __________________________________________________________________
Month Year
( ) Full-time__________________________________ ( ) Part-time_______________________________________________
( ) Full-time__________________________________ ( ) Part-time_______________________________________________
EDUCATION
High School diploma/GED: ( ) Yes ( ) No If no, indicate highest grade attended:______________________________________________
Name of colleges, universities, or Degree or
Other post-secondary institutions attended Dates diploma
(list most recent education first) Attended Major/ Area of Study earned
______________________________ _ _____to______ _ ______________ _ ____________________
___________________________________ _ _____to______ _ ______________ _ ____________________
___________________________________ _ _____to______ _ ______________ _ ____________________
TEACHING EXPERIENCE (For academic professionals only)
Community College ( ) Full-time ( ) Part-time
4-year college or university ( ) Full-time ( ) Part-time
High School or elementary setting ( ) Full-time ( ) Part-time
Other education setting ( ) Full-time ( ) Part-time
If applying for a teaching position, you must include transcripts/credentials.
OTHER PERTINENT INFORMATION
Have you been employed previously by Butler County Community College?
_______________________________________________________________________________________
( ) Yes ( ) No If yes, give dates
Are you legally authorized to work in the United States?* ( ) Yes ( ) No
Have you ever been convicted of, or pleaded guilty or “no contest” to a felony or criminal offense, excluding misdemeanors and traffic
offences? ( ) Yes ( ) No
If yes, please explain
Briefly_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
“A conviction record will not necessarily be a bar to employment. Factors such as length on incarceration, the seriousness and nature of the
offense, and the applicant’s rehabilitation will be considered in the hiring decision.”
SKILLS AND CERTIFICATIONS
List all valid professional licenses and registration you hold. Include certification/ registration number and expiration date.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
__________________________________________________________
List other employment skills, special training or related courses that you would like considered as part of your application.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Briefly describe significant contributions and achievements, including academic awards, scholarships, and publications in professional and/or
civic organizations that you would like considered as a part of your application.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
SECOND LANGUAGE ABILITY
1.) Speak___________________________________ Read_________________________________ Write_____________________________
REFERENCES
1. Current supervisor May we contact your current supervisor? ( )Yes ( ) No
________________________________ _______________________________ ____________________________________________
Name/Title Organization/Phone No. Address
2. List at least 3 persons who have knowledge of your work experience or education.
(Do not include relatives, personal friends, or immediate supervisors already listed in the employment section)
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
EMPLOYMENT HISTORY
Provide complete information for all current and past employment. Begin with present or most recent employment.
Attach additional employment history if necessary.
Position:
____________________________________________________________________________________________________________________________________________________________________________________
From To Immediate Supervisor Current/Final Salary
Employer Name:_________________________________________________________________________________________________________________________________________________________________________
Address and Phone
:______________________________ _________________________ _____________ __________ ( ) _____________________ _______________________
Street City State ZIP Phone Ext.
Full time or Part time Duties:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________________________________________________________________________________________________
Position:
____________________________________________________________________________________________________________________________________________________________________________________
From To Immediate Supervisor Current/Final Salary
Employer Name:_________________________________________________________________________________________________________________________________________________________________________
Address and Phone
:______________________________ _________________________ _____________ __________ ( ) _____________________ _______________________
Street City State ZIP Phone Ext.
Full time or Part time Duties:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________________________________________________________________________________________________
Position:
____________________________________________________________________________________________________________________________________________________________________________________
From To Immediate Supervisor Current/Final Salary
Employer Name:_________________________________________________________________________________________________________________________________________________________________________
Address and Phone
:______________________________ _________________________ _____________ __________ ( ) _____________________ _______________________
Street City State ZIP Phone Ext.
Full time or Part time Duties:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________
Reason for Leaving: ___________________________________________________________________________________________________________________________________________________________________
Position:
____________________________________________________________________________________________________________________________________________________________________________________
From To Immediate Supervisor Current/Final Salary
Employer Name:_________________________________________________________________________________________________________________________________________________________________________
Address and Phone
:______________________________ _________________________ _____________ __________ ( ) _____________________ _______________________
Street City State ZIP Phone Ext.
Full time or Part time Duties:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________
Reason for Leaving:
___________________________________________________________________________________________________________________________________________________________________
Please explain any breaks or periods of unemployment in your employment history:
From:______________________ To:______________________________ Reason: ____________________________________________________________
From:______________________ To:______________________________ Reason: ____________________________________________________________
From:______________________ To:______________________________ Reason: ____________________________________________________________
APLICATION CERTIFICATION AND AUTHORIZATION RELEASE
I hereby authorize investigation of all statements contained in this application. I certify by the signature below that all
statements are true and correct, and that misrepresentation or omission of facts called for in this form is sufficient cause
for termination of employment without notice. If employed, I agree to comply with all policies, procedures, and
regulations of Butler County Community College and applicable local, state, and federal laws currently existing or that
may exist in the future.
A resume, or other appropriate materials may be included with application but may not be submitted instead of
the application. If employed, the college may require certified transcripts for any college-level education listed on this
application.
Information provided on this application will become part of your permanent personal record if you are employed at
Butler. Materials submitted for consideration as part of the application for employment are not returnable.
Butler Community College is committed to nondiscrimination on the basis of gender, race, color, national origin, age,
religion, mental or physical disability, marital or parental status, or status as a veteran. Employment decisions are based
strictly on job related qualifications and an individual's ability to perform the job.
To report discrimination under Title IX (sex) contact the Title IX Coordinator at 316-323-6942. To report
discrimination under Section 504 (handicap) contact the Coordinator of Special Needs/ADA Compliance Officer at
316-322-3321 (local) or 316-733-3321 (W ichita Metro). You may also contact the Director of Human Resources at
316-322-3152 (local) or 316-733-3152 (Wichita Metro). These offices are located at 901 S. Haverhill Rd., El Dorado,
KS, 67042.
DATE_________________________________ SIGNATURE_____________________________________________
BUTLER COMMUNITY COLLEGE IS AN
EQUAL OPPORTUNITY EMPLOYER
Revised 5/2010
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Employment-application EMPLOYMENT APPLICATION

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Completed 16 February 2020

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