John A. Logan College Non-Teaching Professional
Carterville, Illinois 62918 Application
Form
NEPOTISM STATEMENT
John A.
Logan College has a policy on hiring relatives, so the Office of Human Resources needs to inquire
about family working for the College. The “family” list below includes those relationships that the
College considers under its nepotism policy.
While the College is committed to hiring the most qualified candidates, and is committed to hiring
individuals solely on the basis of their qualifications and suitability for the job, family members of the
Board of Trustees (excluding student trustee) or full-time faculty and staff may not be considered for
employment at John A. Logan College.
FAMILY - is defined to mean the husband, wife, child, or child’s spouse, parent or parent’s spouse,
brother or brother’s spouse, sister or sister’s spouse, domestic partner and individuals in the same
household. “Family” also includes an employee or board member’s spouse’s child, parent, brother, or
sister.
This policy does NOT apply to part-time employees, including student workers.
Does anyone related to you, as described on the list, work for the College, in any capacity including: full-
time, temporary, grant, or under contract? A positive answer does not necessarily eliminate you from
consideration.
Yes No If yes, describe:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Applicant Na
me: __________________________________________________________
Applicant signature: __________________________________________________________
Date: __________________________________________________________
John A. Logan College is an equal opportunity/affirmative action employer and encourages applications
from all qualified candidates.
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John A. Logan College Non-Teaching Professional
Carterville, Illinois 62918 Application
Form
Please print or type the following informati
on: Date: _______________________
Last Name: ______________________________ First Name: ____________________ Middle Initial: ______
Address: ___________________________________________________________________________________
Street/P.O. Box
_______________________________________ ______________ ____________
City State Zip Code
Home
Telephone
Business
Telephone
Cell
Telephone
E
-mail Address:
S
ocial Security No.
Position Desir
ed
(be specific) ___________________________________________________________________________________
1. When will you be able to begin work?
_________________________________________________________
2. Please indicate how you learned of John A. Logan College as a source of employment.
Employee Bulletin Student Agency
Newspaper Website Other (please specify) __________________
_
3. If hired, will you consent to an employment physical? Yes No
4. If hired, will you fur
nish proof of age? Yes No
5. Are you a U.S. citizen, or do you have a legal right to work in the U.S.? Yes No
Immigration status ______________________________________________
6. If you are not a U.S. citizen, can you provide an authorized work permit? Yes No
7. Are y
ou a veteran of the U.S. armed forces? Yes
No
Branch of service _______________________ Entrance date ___________
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Academic Training
Highest degree
now held ________________________________________________________________________
Credit hours earned beyond highest degree ___________________ (semester) ___________________ (quarter)
Major field ____________________________________________________________________________________
Now a candidate for ______________________________________________________________________ degree
to be conferred on or about ________________.
Formal Education
College or University
(undergraduate) City/State
Major/Minor
Field(s) of Study
Degree & Date or
Date Last Attended
University
(graduate/professional) City/State
Major/Minor
Field(s) of Study
Degree & Date or
Date Last Attended
Professional Certificates or Licenses
(such as Certified Public Accountant) Certificate or Degree & Field Dates
Transcripts must be submitted to meet the minimum application requirement.
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Relevant Employment History
Begin with the most recent employment and list all jobs in reverse order. Please include employment dates, title,
reason for leaving, and a brief description of duties and responsibilities performed for each listed employer. You
must provide employment history on this page, even if you are submitting a resume.
PLEASE DO NOT USE “SEE RESUME”.
EMPLOYER
(Name and Address)
EMPLOYMENT DATE
S
From
(Mo/Yr)
To
(Mo/Yr)
Title Held
Duties & Responsibilities:
Telephone: Reason for
S
upervisor: Leaving:
Duties & Responsibilities:
Telephone: Reason for
Leaving:
S
upervisor:
Duties & Responsibilities:
Telephone: Reason for
S
upervisor: Leaving:
Duties & Responsibilities:
Telephone: Reason for
S
upervisor: Leaving:
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Have you ever been suspended or discharged from any position? Yes No
If yes, give reason for suspension or discharge. ______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Memberships in Honor Societies & Learned & Professional Organizations
List those relevant to the position.
_____________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Scholarships, Prizes, Honors, or Other Recognitions, & Publications
List those relevant to the position.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
References
References may be personal or business references. Please do not use relatives or employers listed on preceding
page.
Name & Address of Reference
Profession, Business, or
Occupation of Reference
Telephone:
Telephone:
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References Continued
Name & Address of Reference
Profession, Business, or
Occupation of Reference
Telephone:
Telephone:
Do we have your permission to contact employers and references? Yes No
Place an “X” before those employers and/or references that you do not wish to be contacted without your
permission.
Public Law 91-508 requires that we advise you that a routine inquiry may be made which will provide applicable
information concerning character, general reputation, and personal characteristics.
Educational Loan Certification
All applicants must complete the following section as required by Illinois State Law (Public Act 85-827).
Information obtained will not be used as a factor in considering your application for employment.
Please check one of the following:
I certify that I am not in default on an educational loan guaranteed by the Illinois Student Assistance
Commission under the Higher Education Student Assistance Law, any education loan made by an
institution of higher education from the proceeds of a loan to the institution by the Illinois Independent
Higher Education Loan Authority under the Illinois Independent Higher Education Loan Authority Act, or
any other loan from public funds made for the purpose of financing an individual’s attendance at an
institution of higher education in the amount of $600 or more.
I certify that I am in default on an educational loan guaranteed by the Illinois Student Assistance
Commission under the Higher Education Student Assistance Law, any education loan made by an
institution of higher education from the proceeds of a loan to the institution by the Illinois Independent
Higher Education Loan Authority under the Illinois Independent Higher Education Loan Authority Act, or
any other loan from public funds made for the purpose of financing an individual’s attendance at an
institution of higher education in the amount of $600 or more.
If I am employed by the College, I agree as a condition of employment, to make arrangements for
repayment of this loan with the maker or guarantor within 6 months from the date of employment.
I understand that failure to do so will result in termination of employment.
Signature of Applicant ____________________________________________ Date: _____________________
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Consent
I understand that any false answer or statements made by me on this application, or any supplement thereto, may
be grounds for immediate discharge.
Immigration Reform. The Immigration Reform and Control Act of 1986 requires all employers to verify the identity
and employment authorization of all new employees. If you are hired, it will be necessary for you to furnish this
documentation. If any doubt exists regarding your eligibility for employment, you will be asked to show your visa
and/or work permit.
Signature of Applicant ____________________________________________ Date _____________________
Verification of Education & Experience
A John A. Logan College application is required for any position. Unofficial transcripts (certificates) are acceptable
for applicants qualifying on the basis of college or vocational training to meet minimum qualifications. Official
transcripts (certificates) and verification of experience are required prior to appointment to a position.
Submission of Application Materials
Submit application materials to Human Resources, Room C116.
John A. Logan College
700 Logan College Road
Carterville, IL 62918
For further information, contact Human Resources, Ext. 8273, at one of the following toll-free numbers:
Carterville and Williamson County .............................................................. (618) 985-3741 (operator)
(618) 985-2828 (direct extension access)
Carbondale and Jackson County .................................................................. (618) 549-7335 (operator)
(618) 457-7676 (direct extension access)
Du Quoin ...................................................................................................... (618) 542-8612
West Frankfort ............................................................................................. (618) 937-3438
Crab Orchard, Gorham, & Trico areas ......................................................... 1-800-851-4720
The John A. Logan College home page is accessible at http://www.jalc.edu.
John A. Logan College does not discriminate on the basis of race, religion,
color, national origin, disability, age, sexual orientation, or gender orientation.
10-24-19
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AUTHORIZATION TO DO CRIMINAL BACKGROUND CHECK
In co
nnection with your application, you hereby authorize John A. Logan College to obtain and furnish
reports from various agencies regarding your criminal history to John A. Logan College for employment purposes.
The amended Fair Credit Reporting Act (1997) requires that we inform you that a background check may
be conducted as part of our employment screening process. The main objective of the background check is to
verify information you provided on your application/resume or during the interview process. In the event that any
report from an outside agency is utilized in making an adverse decision regarding your potential employment, JALC
will provide you with an address to obtain a copy of the information or report and a description in writing of your
rights under the law prior to making such an adverse employment decision. We will provide you with the
disclosure within five (5) business days of the date on which we receive your written request.
I hereby authorize and request all circuit courts and their officers, officials and employees, state
agencies and their officials and employees, local and state law enforcement agencies, federal law enforcement
agencies, International law enforcement agencies having criminal information relevant to my background for
employment purposes, to release any and all information upon John A. Logan College’s request. I further
release, hold harmless and agree to indemnify any of the foregoing from any and all liability, injury, damages,
claims, demands, causes of action, suits, judgments and executions, whether sounding in tort, contract, equity
or law, which I and my heirs, personal representatives, assigns, executors and administrators now have, or in
the future may have, against any of the foregoing for providing the requested reports to John A. Logan College.
PLEASE TYPE OR PRINT LEGIBLY
Last Name: ____________________________ First
Nam
e: ________________ Middle Name: __________
Other names known by (including maiden): _________________________________________________________
Address: ___________________________________________________________________________________
Street/P.O. Box, City, State, Zip Code, County
Date of Birth Driver’s License
#
S
tate
S
Male Female
Home Address
es for the Past 7 Years:
S
treet Address City
S
tate County Dates Mo/Year
Previous Felony
/Misdemeanor Criminal Convictions?
Yes No
Charge/Conviction County
S
tate Dates Mo/Year
By my signature below, I hereby authorize JALC to obtain my criminal history. I hereby state that I have read this document in detail and
clearly understand the terms and rights that I have granted to JALC for the collection and release of the aforementioned information.
Signature of A
pplicant ____________________________________________ Date ______________
A conviction record will not necessarily be a bar to employment, and factors such as age at the time of the offense, seriousness and nature
of the violation, and rehabilitation will be considered.
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JALC SURS ANNUITANT VERIFICATION FORM
John A. Logan College
Office of Human Resources
Carterville, IL 62918
618-985-2828 ext. 8273 FAX: 618-985-3906
SURS ANNUITANT VERIFICATION FORM
Any college or university that employs an “affected annuitant”¹ is required to make
contributions to the State Universities Retirement System (1-800-ASK-SURS or
www.surs.org) equal to the affected annuitant’s annualized retirement annuity (Public Act
97-0968). As a condition of your employment, you must verify your SURS annuitant status.
You may also be required to provide sufficient information to confirm your status.
Please answer the question(s) below and provide the information requested. This form and
the requested information must be returned to the Office of Human Resources prior to
employment.
______________________________________________________________________
Have you ever been employed by a SURS employer? NO __ Proceed to page 2, YES
Complete Questions 1 – 6.
1. I AM an “Affected Annuitant”, No ___ Yes ___
2. I AM ___/ AM NOT___ (check the applicable answer) receiving a retirement annuity
from SURS.
3. I WILL___/ WILL NOT___ (check the applicable answer) suspend my annuity
payment from SURS.
4. I WILL___/ WILL NOT___ (check the applicable answer) become an “affected
annuitant” as defined under SURS based on my current academic year employment
or my anticipated employment in the academic year for which I am seeking
employment by the College.
5. Do you currently work for another SURS entity? NO ___ YES___ (check the
applicable answer). If yes, please list the other SURS entities you are employed by.
____________________________________________________________________
_______________________________________________________________________
6. Do you intend to work for another SURS entity in the academic year for which you are
seeking employment by the College? NO___ YES__ (Check the applicable answer).
If yes, please list the other SURS entities you anticipate working for.
______________________________________________________________________
______________________________________________________________________
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If you are a current SURS annuitant who wants to work full-time for John A. Logan College
you must suspend your annuity. To take action, you must request the following form directly
from SURS: “Election to Forego the Receipt of Annuity Payments during Reemployment”.
The College recommends you receive counseling from SURS on the impact of filing this
form and the temporary stoppage of your annuity payment. The Human Resources
department must receive a copy of the form you have filed with SURS and receive
verification from SURS regarding stoppage of payments and effective date. Upon receipt of
the required information and documentation your employment may begin. During
employment SURS will be deducted from your wages. As the annuitant you are responsible
for contacting SURS regarding reinstating your annuity payment when employment ends.
Verification
The information in this SURS Annuitant Verification Form is true, correct and complete
to the best of my knowledge and belief. I understand that any misrepresentation or
omission of fact, as stated or implied on this form is sufficient reason for not hiring me
and will result in my immediate dismissal if already hired.
Signature: ______________________________________
Date: __________________________________________
Printed Name: __________________________________
NOTE: A person receiving a retirement annuity from the System becomes an "affected
annuitant" on the first day of the academic year following the academic year in which
the annuitant first meets both of the following conditions:
(1) While receiving a retirement annuity under this Article, the annuitant has been
employed on or after August 1, 2013 by one or more employers under this Article
for a total of more than 18 paid weeks (which need not have been with the same
employer or in the same academic year).
(2) While receiving a retirement annuity under this Article, the annuitant was
employed on or after August 1, 2013 by one or more employers under this Article
and received or became entitled to receive during an academic year
compensation for that employment in excess of 40% of his or her highest annual
earnings prior to retirement. Paid weeks worked by an employed annuitant in
which the annuitant is compensated solely from federal, foundation, trust, or
corporate funds, or state grants in which the principal investigator is named are
excluded from the paid weeks condition.
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