Fillable MSCApplicationforEmployment060116FINAL

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MSCApplicationforEmployment060116FINAL

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  • 173 check-boxes
  • 149 other fields

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File type: PDF

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Page
1
Tishomingo, Oklahoma - Ardmore, Oklahoma
APPLICATION FOR
EMPLOYMENT
Please return this application
to:
Human Resource Director
Murray State
Coll
ege
One Murray Campus, Suite AD
104
T
i
s
h
o
ming
o
,
OK
7
3
46
0
Specific
Position or Type of Position
Applied for:
Full-Time Part-Tim
e
Last Name First Name Middle Name
Dat
e
Mailing
Addr
ess
Home/Cell
Ph
o
n
e
City, State,
Zip
Business
Ph
on
e
Have you ever applied for
e
mploy
m
e
n
t
with
u
s?
Yes No
Month/Year :
Social Security #
Are you
l
e
g
ally
e
li
g
i
b
l
e
for
e
mp
l
o
ym
e
nt in the
U
.
S
.
?
Yes
No
Documentation of identity and employment eligibility must be provided upon hire as required by
Immigration Reform and Control Act of 1986 (Form I-9).
Are you able to work a flexible schedule?
Yes
No
Do you have a valid driver's license?
Yes No
Are you fluent in any language other than English?
Yes No
If so, please specify
Special training or skills and qualifications (additional sheet(s) can be attached if needed):
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2
Education
List any education that you have received if such education is required or preferred for the position for which you are applying.
List name and location of school and
diploma/degree earned (Include high school, vocational school and college/university &
graduate school. Verification of all levels of education may be required. Official transcripts, diploma, or certification will be
required if offered a position, however, to meet application deadline, copies are acceptable.)
City, State
Number of
Hours
Completed
Diploma or
Type of Degree
Received
Area of
Study/Major
Professional License/Certifications
List any professional or occupational license, registration or certification (i.e., Certifi ed Public Accountant, Certified Procurement
Officer etc.) and attach copies
Professional License,
Registration or Certification
Date
Received
License Number if
Applicable
Expirati
on Date
Licensing Agency or Board
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Page 3
Employment Related Skills
(Check appropriate answer)
Skills Inventory
Proficient
No Skill
Skills Inventory
Proficient
Some
Skill
No Skill
Computer Software
Skilled Craft
MS Word
Blueprint Reading
Excel
Carpentry
PowerPoint
Electrical
Access
HVAC
MS Outlook
Painting
Other
Plumbing
Roofing
Clerical
Water Treatment
Accounting
Welding
Data Entry
Equipment Repair
Editing
Other
Filing
Payroll Records
Custodial Services
Personnel Records
Chemical Knowledge
Receptionist
Commercial Cleaning
Technical Typing
Stripper
Other
Waxer
Office Machines
Buffer
Fax
Other
Telephone System
Voice Mail
Mechanical
Document Scanner
Small Engine
Typing Skill/WPM
Heavy Equipment Diesel
Other
Building
Grounds
Other
List any other applicable licenses, certificates, registrations or permits:
________________________________________________________________________________________
Have you supervised or directed the work of others? Yes No
Length of time____________________ Number of persons_____________
Employment History
If any employment was under a different name, indicate name:
Have you ever been discharged or asked to resign from a job? Yes No
Explain
Some
Skill
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4
Employment
Record
(List current or most recent
first)
Employer
Employer's
Address:
Street
City
State
Zip
Employer Phone
No.
Supervisor Phone
No.
Immediate
Supervisor
Supervisor's Title
Your
Title/Rank
Department
Starting
Salary
Last or Present
Salary
Date
Employed
Date
Separated
Specific
Duties (Describe your work experience in detail. Employers and supervisors may be contacted regarding
your work experience.)
Reason for
Leaving
Employer
Employer's
Address:
Street
City
State
Zip
Employer Phone
No.
Supervisor Phone
No.
Immediate
Supervisor
Supervisor's Title
Your
Title/Rank
Department
Starting
Salary
Last or Present
Salary
Date
Employed
Date
Separated
Specific
Duties (Describe your work experience in detail. Employers and supervisors may be contacted regarding
your work experience.)
Reason for
Leaving
2
Page
5
Employment
Record-Continued
(List current or most recent
first)
Employer
Employer's
Address:
Street
City
State
Zip
Employer Phone
No.
Supervisor Phone
No.
Immediate
Supervisor
Supervisor's Title
Your
Title/Rank
Department
Starting
Salary
Last or Present
Salary
Date
Employed
Date
Separated
Specific
Duties (Describe your work experience in detail. Employers and supervisors may be contacted regarding
your work experience.)
Reason for
Leaving
Employer
Employer's
Address:
Street
City
State
Zip
Employer Phone
No.
Supervisor Phone
No.
Immediate
Supervisor
Supervisor's Title
Your
Title/Rank
Department
Starting
Salary
Last or Present
Salary
Date
Employed
Date
Separated
Specific
Duties (Describe your work experience in detail. Employers and supervisors may be contacted regarding
your work experience.)
Reason for
Leaving
This form may be duplicated for submission of additional employment records.
*(If you have more than four separate period of employment, complete a blank sheet in the above format; sign and attach to this application.)
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6
References
Reference 1
Name
Number of Years Acquainted
Address
E-mail
City, State, Zip
Telephone
Occupation
Reference 2
Name
Number of Years Acquainted
Address
E-mail
City, State, Zip
Telephone
Occupation
Reference 3
Name
Number of Years Acquainted
Address
E-mail
City, State, Zip
Telephone
Occupation
*Please read the following information carefully, then sign and date below.
ACCURACY OF INFORMATION: By signing this application, I certify that the information supplied in this application and in any other form,
oral or written, is true and accurate.
FALSIFICATON OF INFORMATION: I understand and agree that any misstated, misleading, incomplete or false information is grounds for
my disqualification from consideration for employment, for withdrawal of any offer of employment if any offer has been made, or for my
immediate discharge if employment has already commenced, whenever, and however discovered. I also understand that Section 358(B) of
Title 21 of the Oklahoma Statutes prohibits applicants for state employment from making a materially false, fictitious, or fraudulent statement
or representation on any employment application, knowing such statement or representation to be materially false, fictitious, or fraudulent.
Violation is a criminal offence, punishable by fine and/or imprisonment.
VERIFICATION OF INFORMATION: I hereby authorize Murray State College to verify the information I have provided in my employment
application, in my oral statements and in any other documents or supplemental information I have provided for the purposes of employment.
This shall include the authorization to conduct any and all personal background checks, including but not limited to, criminal history and
related records, education and employment background records, civilian and military court records and/or proceedings. I authorize any
former employers and job-related references to provide any information requested by Murray State College. I release from liability and hold
harmless the State of Oklahoma, Murray State College, the MSC Board of Regents, employees and attorneys, along with corporation, firm,
person, organization or individual providing information to Murray State College, from any and all claims, liabilities, loss, demands and
causes of action known and unknown, fixed or contingent, equitable, legal or administrative, accrued to me as a result of such disclosure of
information concerning me.
REQUIRED DOCUMENTS: I understand that if I fail to attach any other required documents, i.e., transcripts, letters of recommendation,
etc., listed on a job description for an advertised position, I may be excluded from further consideration.
EMPLOYMENT ELIGIBILITY: I understand that if I am hired I will be required to produce proof that I have a legal right to work in the U.S.A.
in accordance with the Immigration Reform and Control Act of 1986. This agency verifies the identity and employment eligibility status of all
2
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7
newly hired employees utilizing the Form I-9 verification process as well as the E-Verify Program with the Department of Homeland Security
and the Social Security Administration.
GENERAL: If selected for employment, I agree to submit to a pre-employment drug/alcohol screen as requested by my employer in
conjunction with the hiring process. If selected for employment, I agree to participate in random drug/alcohol screenings as requested. I
agree to conform to the policies, procedures, rules and regulations of Murray State College and the MSC Board of Regents. In connection
with being considering me for employment, continued employment, promotion, or reassignment, MSC may obtain a consumer report which
may include information on character, general reputation, personal characteristics, and mode of living from public record sources or
personal interviews with previous employers or associates. I understand that I have the right, upon written request, to receive a written
description of the nature and scope of the investigation requested and a written summary of my rights under the Fair Credit Reporting Act. If
consumer information from my credit report or another type of consumer report is used to deny employment or if any other adverse action is
taken I understand I will be given the name, address, and phone number of the agency that provided the information.
With this application, I agree to the College's overtime policy for non-exempt employees, which allows giving compensatory time off in lieu of
payment of overtime worked. I understand that the position for which I am submitting this application may be at-will. The applicant selected
for any at-will position will serve at the will of the College. If selected for a position, I understand my employment and compensation can be
terminated, with or without cause, and with or without notice, at any time, at the option of either Murray State College or myself. I
understand that no representative of the College has any authority to enter into any agreement for continued employment for any specified
period of time or to make any agreement contrary to the foregoing. If an employee resigns or is discharged, full payment of unused annual
leave (excludes sick leave and personal leave) will be made upon approval of the Vice President for Finance and Administration, provided
the employee has worked for a continuous six month period and appropriate notice was given. No payment for annual leave will be
authorized for any person who has not completed at least six months of continuous employment at the College. Any compensatory time
accrued and not used will be paid the month following final paycheck.
__________________________________________________________ __________________________
Applicant Signature Date
Application materials received from applicants become the property of Murray State College. Materials for applicants who are not chosen to fill a position
will remain on file only for the time limit stipulated in accordance with the State's archival procedures.
Equal Opportunity Statement In Compliance with Title VI of the Civil Rights Act of 1964, Executive Order 11246 as
amended, Title IX of the Education Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, and
other Federal Laws and Regulations, Murray State College does not discriminate on the basis of race, color, national
origin, sex, sexual identity, sexual orientation, age, religion, handicap, disability, or status as a veteran in any of its
policies, practices or procedures, this includes but is not limited to admissions, employment, financial aid, and educational
services.
Title IX of the Education Amendments of 1972 (20 U.S.C. § 1681) states: No person in the United States, shall, on the
basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any
education program or activity receiving federal financial assistance…” Murray State College does not discriminate on the
basis of sex in its education programs or activities, in compliance with Title IX and the U.S. Department of Education’s
regulations at 34 C.F.R. §§ 86.1 et seq. Individuals who believe they have been discriminated against on the basis of sex
may contact MSC's Title IX Coordinator at 580-387-7131, mgray@mscok.edu, or Murray Hall Administration Building,
Suite 104.
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VOLUNTARY INFORMATION REQUEST: NOT TO BE USED IN HIRING DECISIONS
Equal Employment Opportunity Information Request
The information requested within this section is solely for statistical reporting purposes in the implementation of nondiscrimination
provisions of Federal and State law and our affirmative action program. Your submission of this information is optional. Your
decision not to complete this section will not affect consideration of your application or subject you to any adverse treatment. When
you have completed this form, please send it directly to the Affirmative Action Officer/Human Resource Director at Murray State
College, One Murray
Campus,
Tishomingo, OK 73460.
Race/Ethnic Data: (Mark all that apply)
1. Asian
2. American Indian or Alaskan Native
3. Black or African American
4. Hispanic
5. Native Hawaiian or Other- Pacific Islander Included 
6. Non-Resident Alien
7. Race & Ethnicity Unknown
8. White
9. I do not wish to enter voluntary self-identification EEOC information.
Veterans Status: Veteran Yes No
Vietnam Era Veteran Yes No
A Vietnam Veteran is any veteran of the US armed services who served on active duty for at least 180 days, any part of which occurred between
February 28, 1961 and May 7m, 1975 and was discharged for release therefrom with other than a dishonorable discharge, or was discharged or
released from active duty for a service-connected disability if any part of such active duty was performed between August 6, 1964 and May 7, 1975.
(Murray State College will make reasonable accommodations for otherwise qualified applicants.)
The
following
definitions may be of help to you in completing this sheet:
Disability: Any physical and/or mental condition which
might
substantially limit you in securing, retaining or advancing in
employment. If you are disabled, you should check the "yes" box above. The information will be kept confidence and will be used
only in conjunction with our affirmative action program under the Rehabilitation Act of 1973.
Name:
(Last Name (First) (MI) Gender: Male Female
Position Applied for:
Murray State College, in compliance with Title VI and Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section
503 of the Rehabilitation Act of /973, Section 402 of the Readjustment Assistance Act of 1974, and other federal laws and
regulations,
does not
discriminate on the basis of race, color, national origin, sex, religion, handicap or status as a veteran in any of its policies, practices or procedures.
This includes, but is not limited to admissions, employment, financial aid and educational services.
HR Form: 06.01.16
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MSCApplicationforEmployment060116FINAL

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Completed 30 October 2019

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