Fillable Form 1.: ADJUNCTFACULTYAPPLICATION (Walters State Community College)

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Form 1.: ADJUNCTFACULTYAPPLICATION (Walters State Community College)

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200 other fields

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Morristown,Tennessee37813‐6899

AnEqualOpportunity/AffirmativeActionEmployer

ADJUNCTFACULTYAPPLICATION

(PleasetypeorprintplainlyandreturntothedivisionofDistanceEducation)

Date:

Discipline(s)inwhichyouareinterested inteaching:

1.

2.

3.

1. Name:

last first  middle maiden (if shown on school or

employment records)

2. MailingAddress:

street city state zip code 

Telephone:Home: Other:

E‐MailAddress:Home:

3. AvailabilityRecap:

Willyouteacheveningornightclasses? NoYes Will you teach off-campus classes?No Yes

Dateavailable?

ANSWERALLSECTIONSCAREFULLYANDCOMPLETELY.DONOTUSE“SEERESUMEOROTHERDOCUMENTS.”

ALLSTATEMENTSMADEINTHISAPPLICATIONMAYBEVERIFIED.

4. EducationalBackground:

Lasthighschoolattended:

Address:

NamesandAddressesofCollegesor

UniversitiesAttended

DatesAttended FieldofStudyorAreaofConcentration

TypeofDegree

Obtained&Date

Total

SemesterHrs.

From To Major Minor

5. Experience:Useaseparateblockforeachposition.

Startwithyourpresentpositionandworkback,explainingclearlythe

principaltaskswhichyouperformedineachposition,accounting forallperiodsofemployment.Useadditionalpagesif

furtherspaceisneeded.

Ifyouhaveneverbeenemployedorarenowunemployed,indicatethatfactinthespaceprovidedbelow:

Doyouhaveobjectionstoyourpresentemployerbeingcontactedpriortothetimeofinterview?



No YesNA

YourTitle NameandTitleofImmediateSupervisor

FirmName Address/Phone

LengthofEmployment Total AnnualSalary 9months/

12months

ReasonforLeaving

From To Years Months

Duties

YourTitle NameandTitleofImmediateSupervisor

FirmName Address/Phone

LengthofEmployment Total AnnualSalary 9months/

12months

ReasonforLeaving

From To Years Months

Duties

YourTitle NameandTitleofImmediateSupervisor

FirmName Address/Phone

LengthofEmployment Total AnnualSalary 9months/

12months

ReasonforLeaving

From To Years Months

Duties

YourTitle NameandTitleofImmediateSupervisor

FirmName Address/Phone

LengthofEmployment Total AnnualSalary 9months/

12months

ReasonforLeaving

From To Years Months

Duties

YourTitle NameandTitleofImmediateSupervisor

FirmName Address/Phone

LengthofEmployment Total AnnualSalary 9months/

12months

ReasonforLeaving

From To Years Months

Duties

6. AutobiographicalStatement(RequiredofALLfacultypositions).Writeastatementconcerningyourpersonalbackground

includingsomenoteworthyexperienceyouhavehadorinterestingactivityinwhichyouhavebeenengagedwithinthelast

fiveyears.Attachadditionalpagesifnecessary.

7. ProfessionalPublications:

8. ProfessionalAssociations:

9. AreyouacurrentorpreviousemployeeoftheStateofTennesseeorTennesseeBoardofRegents:No Yes

If“Yes”pleaseprovideinformationbelow:

From To

DepartmentorAgency

Month Year Month Year

10. RelativescurrentlyemployedatWaltersStateCommunityCollege: None Yes(if“yes”,listname,positionand

relationship:

11. AreyoulegallyeligibletoworkintheU.S.?NoYes

12. Willyounow,orinthefuture,requirevisaorH1BSponsorship?NoYes

13. Doyouhaveavaliddriver’slicense?NoYes

14. Haveyoueverbeendismissedfromemploymentforcause?NoYesIf“yes”,pleaseexplain:

15. AreyourequiredtoregisterasasexoffenderunderTCATitle40,Chapter39,Part2?NoYes

BecauseTCA40‐39‐211prohibitssexoffendersrequiredtoregisterunderTCATitle40,Chapter39,Part2fromknowingly

acceptingemploymentwithinonethousandfeet(1,000’)ofthepropertylineofanypublicschool,privateorparochialschool,

licenseddaycarecenter,otherchildcarefacility,publicpark,playgroundrecreationcenterorpublicathleticfieldavailablefor

usebythegeneralpublic,registeredsexoffendersarenoteligibleforemploymentatmanyTBRinstitutions.

16. REFERENCES:Listbelowatleastfourreferencesnotrelatedtoyouwhohavefirsthandknowledgeofyourcharacter,

personality,scholarship,andqualifications.

NameandPosition Address Telephone

17. ATTACHMENTS: A resume may be attached but MAY NOT be used in lieu of application.

18. This application will not be considered complete until official transcripts covering college or university work have been

received by the division of Distance Education. Unofficial copies of transcripts are acceptable for applicant processing

purposes.

________________________________________

WaltersStateCommunityCollege doesnotdiscriminateagainststudents,employees,orapplicantsforadmissionoremploymentonthebasisof

race,color,religion,creed, nationalorigin,sex, sexual orientation,genderidentity/expression,disability,age,statusas aprotected veteran,genetic

information,oranyotherlegallyprotectedclasswithrespecttoallemployment,programsandactivitiessponsoredbyWaltersState

CommunityCollege.Thefollowingpersonhasbeendesignatedtohandleinquiriesregardingnon‐discriminationpolicies:

Nameand/orTitle:

Jarvis Jennings

EmailAddress:

Jarvis.Jennings@ws.edu

Address: 500S.DavyCrockettParkway,Morristown,TN37816‐6899

TelephoneNumber: 423‐585‐6845

WaltersStateCommunityCollege’spolicyonnondiscriminationcanbefoundatwww.ws.edu.

RELEASEOFINFORMATIONTOWALTERSSTATECOMMUNITYCOLLEGE

20. CERTIFICATIONOFAPPLICATION:Iherebycertifythatallinformationcontainedinthisapplicationistrue,completeand

accuratetothebestofmyknowledge.Ialsoauthorizeanynecessaryinvestigationsandthereleaseoftranscriptsandother

personalinformationrelativetomyemployment.DocumentsobtainedbecomesubjecttotheTennesseePublicRecordsAct,

T.C.A.10‐7‐101,et.seq.Iunderstandthatmisrepresentationofthisinformationmaysubjectmetodisqualificationfor

compensationforanyjobortoterminationofemploymentifemployedbyanyagencyofTennesseeStateGovernment.

Signature Date

Pleaseaddressallcorrespondenceconcerningemploymentto: Divisionof

DistanceEducation

WaltersStateCommunityCollege

500S.DavyCrockettParkway

Morristown,TN37813‐6899

423‐585‐6996Fax:423‐585‐6917

WSCC 19347-13400 Rev.5/15

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signature

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VoluntaryDemographicData

Theinformationrequestedbelowistobegivenvoluntarily;refusaltogiveitwillnotsubjectyoutoanypenalty.

Gender:Male

Female

DoyouconsideryourselftobeofHispanic,LatinoorSpanishOrigin?(ApersonofCuban,Mexican,PuertoRican,

SouthorCentralAmerican,orotherSpanishcultureororigin,regardlessofrace.Theterm“Spanishorigin”canbe

usedinadditionto“HispanicorLatino.”) No Yes

Inaddition,selectoneormoreof

thefollowingracialcategoriesto

describeyourself

White

BlackorAfricanAmerican

Asian

AmericanIndian

AlaskanNative

NativeHawaiianorOtherPacificIslander

*Citizenship:

US

Other

*EmploymentEligibility:

Currentfederallawrequiresidentificationandeligibility at the time of employment.

Name:

last first middle maiden

Signature: Date:

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signature

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VoluntarySelf‐IdentificationofDisability

FormCC‐305

OMBControlNumber:1250‐0005

Expires1/31/17

________________________________________

Section503oftheRehabilitationActof1973,asamended.Formoreinformationaboutthisformortheequalemploymentobligationsoffederalcontractors,

visittheU.S.DepartmentofLabor’sOfficeofFederalContractCompliancePrograms(OFCCP)websiteatwww.dol.gov/ofccp.

PUBLICBURDEN

STATEMENT:AccordingtothePaperworkReductionActof1995nopersonsarerequiredtorespondtoacollectionofinformationunlesssuch

collectiondisplaysavalidOMBcontrolnumber.Thissurveyshouldtakeabout5minutestocomplete.

Whyareyoubeingaskedtocompletethisform?

Becausewedobusinesswiththegovernment,wemustreachoutto,hire,andprovideequalopportunitytoqualified

peoplewithdisabilities’.Tohelpusmeasurehowwellwearedoing,weareaskingyoutotellusifyouhaveadisability

orifyoueverhadadisability.Completingthisformisvoluntary,butwehopethatyouwillchoosetofillitout.Ifyouare

applyingforajob,anyansweryougivewillbekeptprivateandwillnotbeusedagainstyouinanyway.

Ifyoualreadyworkforus,youranswerwillnotbeusedagainstyouinanyway.Becauseapersonmaybecomedisabled

atanytime,wearerequiredtoaskallofouremployeestoupdatetheirinformationeveryfiveyears.Youmay

voluntarilyself‐identifyashavingadisabilityonthisformwithoutfearofanypunishmentbecauseyoudidnotidentify

ashavingadisabilityearlier.

HowdoIknowifIhaveadisability?

Youareconsideredtohaveadisabilityifyouhaveaphysicalormentalimpairmentormedicalconditionthat

substantiallylimitsamajorlifeactivity,orifyouhaveahistoryorrecordofsuchanimpairmentormedicalcondition.

Disabilitiesinclude,butarenotlimitedto:

 Blindness

 Deafness

 Cancer

 Diabetes

 Epilepsy

 Autism

 Cerebralpalsy

 HIV/AIDS

 Schizophrenia

 Musculardystrophy

 Bipolardisorder

 Majo

rdepression

 MultipleSclerosis

(MS)

 Missinglimbsor

partiallymissinglimbs



Post‐traumaticstressdisorder(PTSD)

 Obsessivecompulsivedisorder

 Impairmentsrequiringtheuseofawheelchair

 Intellectualdisability(previouslycalledmental

retardation)

ReasonableAccommodationNotice

Federallawrequiresemployerstoprovidereasonableaccommodationtoqualifiedindividualswithdisabilities.Please

tellusifyourequireareasonableaccommodationtoapplyforajobortoperformyourjob.Examplesofreasonable

accommodationincludemakingachangetotheapplicationprocessorworkprocedures,providingdocumentsinan

alternateformat,usingasignlanguageinterpreter,orusingspecializedequipment.

VoluntarySelfIdentificationof

Disability:

Yes,Ihaveadisability(o

rpreviouslyhadadisability)

No,Idonothaveadisability

Idonotwishtoanswer

YourName:

Signature:

Today’sDate:

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signature

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VoluntarySelf‐IdentificationofProtectedVeteranStatus

ThisemployerisaGovernmentcontractorsubjecttotheVietnamEraVeterans'ReadjustmentAssistanceActof

1974,asamendedbytheJobsforVeteransActof2002,38U.S.C.4212(VEVRAA),whichrequiresGovernment

contractorstotakeaffirmativeactiontoemployandadvanceinemployment:(1)disabledveterans;(2)recently

separatedveterans;(3)activedutywartimeorcampaignbadgeveterans;and(4)ArmedForcesservicemedal

veterans.

Theseclassificationsaredefinedasfollows:

 A“disabledveteran”isoneofthefollowing:

 AveteranoftheU.S.military,ground,navalorairservicewhoisentitledtocompensation(orwhobutfor

thereceiptofmilitaryretiredpaywouldbeentitledtocompensation)underlawsadministeredbythe

SecretaryofVeteransAffairs;or

 Apersonwhowasdischargedorreleasedfromactivedutybecauseofaservice‐connecteddisability.

 A“recentlyseparatedveteran”meansanyveteranduringthethree‐yearperiodbeginningonthedateofsuch

veteran'sdischargeorreleasefromactivedutyintheU.S.military,ground,naval,orairservice.

 An“activedutywartimeorcampaignbadgeveteran”meansaveteranwhoservedonactivedutyintheU.S.

military,ground,navalorairserviceduringawar,orinacampaignorexpeditionforwhichacampaignbadge

hasbeenauthorizedunderthelawsadministeredbytheDepartmentofDefense.

 An“ArmedForcesservicemedalveteran”meansaveteranwho,whileservingonactivedutyintheU.S.

military,ground,navalorairservice,participatedinaUnitedStatesmilitaryoperationforwhichanArmed

ForcesservicemedalwasawardedpursuanttoExecutiveOrder12985.

ProtectedveteransmayhaveadditionalrightsunderUSERRA—theUniformedServicesEmploymentand

ReemploymentRightsAct.Inparticular,ifyouwereabsentfromemploymentinordertoperformserviceinthe

uniformedservice,youmaybeentitledtobereemployedbyyouremployerinthepositionyouwouldhaveobtained

withreasonablecertaintyifnotfortheabsenceduetoservice.Formoreinformation,calltheU.S.Departmentof

Labor'sVeteransEmploymentandTrainingService(VETS),toll‐free,at1‐866‐4‐USA‐DOL.

Ifyoubelieveyoubelongtoanyofthecategoriesofprotectedveteranslistedabove,pleaseindicatebycheckingthe

appropriateboxbelow.AsaGovernmentcontractorsubjecttoVEVRAA,werequestthisinformationinorderto

measuretheeffectivenessoftheoutreachandpositiverecruitmenteffortsweundertakepursuanttoVEVRAA.Your

decisiontoprovidetherelevantinformationispurelyvoluntaryonyourpart,andrefusaltoprovidesuch

informationwillnotsubjectyoutoanyadversetreatment.Theinformationwillnotbeusedinamannerinconsistent

withVEVRAA,asamended.

Theinformationwillbekeptconfidential,exceptthat(i)supervisorsandmanagersmaybeinformedregarding

restrictionsontheworkordutiesofdisabledveterans,andregardingnecessaryaccommodations;(ii)firstaidand

safetypersonnelmaybeinformed,whenandtotheextentappropriate,ifyouhaveaconditionthatmightrequire

emergencytreatment;and(iii)Governmentofficialsengagedinenforcinglawsadministered

bytheOfficeofFederal

ContractCompliancePrograms,orenforcingtheAmericanswithDisabilitiesAct,maybeinformed.

VoluntarySelfIdentificationofProtected

VeteranStatus:

Iidentifyasoneormoreoftheclassificationsofprotected

veteranlistedabove.

Iamnotaprotectedveteran.

Idonotwishtoanswer.

YourName:

Signature:

Today’sDate:

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signature

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FAIRCREDITREPORTINGACT

DISCLOSUREANDAUTHORIZATIONFORM

WaltersStateCommunityCollegemayrequest,orhasdecidedtorequest,aconsumerreportto

beobtainedfromaconsumerreportingagencytoassistinmakingadecisionpertainingtoyour

applicationforemployment,oryourpromotion,reclassification,transferorretentionasan

employeeatWaltersState.

Youareconsidereda“consumer”undertheFairCreditReportingActandhavecertainrights

thereunder. A“co

nsumerreportingagency”isapersonorbusinessthat,formonetaryfees,

regularlyassemblesorevaluatesconsumercreditinformationorotherinformationon

consumer sforthepurposeoffur

nishingconsumerreports. A“consumerreport”isanywritten,

oral,orother

communicationofanyinfo

rmationbyaconsumerreportingagencyconcerningaconsumer’s

creditworthiness,creditstanding,creditcapacity,character,generalreputation,personal

characteristicsormodeoflivingwhichisusedorcollectedforthepurposeofservingasafactor

inestablishingtheconsumer’seligibilityforemploymentpurposes.

Theinformationrequestedmayinclude,bu

tnotbelimitedto,verificationofidentification

and/orSocialSecuritynumber;checksofcriminalhistory,ifany;verificationofemployment,

education,credent ialsorlicensesheldbyyou;andcredithistory. Anyinformationcontainedin

suchre

portsmaybetakenintoconsiderationinevaluatingyoursuitabilityforemployment,

promotion,reclassifica

tion,transferorretentionasanemployee.

Byyoursignaturebelow,youindicatethatyouauthorizeandconsenttotherele aseofconsumer

reportstoWaltersStatetobeusedinconnectionwithyourapplicationforemployment,

promotion,reclassification,transferorretentionatWaltersState. Ifyoufailorrefusetoexecu

te

thisdocument,nofurtherconsiderationbegiventoyourapplicationforemployment,

promotion,reassignmentorretentionasanemployee.

PrintedName

Signature Date

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signature

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Form 1.: ADJUNCTFACULTYAPPLICATION (Walters State Community College)

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