Fillable Martin Community College Employment Application (Martin Community College)

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Martin Community College Employment Application (Martin Community College)

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HR USE ONLY
Martin Community College
Employment Application
1161 Kehukee Park Road
Williamston, NC 27892
www.martincc.edu
An Equal Opportunity Employer
Martin Community College does not discriminate on the basis of race, color, religion, national origin, sex, age or disability. It is the College’s
intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.
________________________________________________________________________________________________________________________
Thank you for your interest in employment with Martin Community College. Our Faculty and Staff strive to build better futures for our
students and the communities we serve. In order for your application to be considered all items must be completed fully and accurately.
APPLICANT INFORMATION
Name: ________________________________________________________________________________ Last 4 digits of SSN: _____________
(First) (Middle) (Last)
Mailing
Address:________________________________________________________________________________________________________________
(Street or PO Box) (City) (State) (Zip)
Physical Address: ________________________________________________________________________________________________________
(If Different) (Street) (City) (State) (Zip)
Home Phone: ________________________ Cell Phone: _________________________ Email: ________________________________________
Are you seeking (check all that apply) Full-Time(<30hr) Part-Time (>25hr) Temp. Employment
Days Evenings Remote
If part-time or temp, please state which days/hours you are available: ____________________________________________________________
When would you be available to begin work? __________________________________
Position Applying for: ____________________________________________________________________________________________________
Please indicate your referral source: MCC Website NCCCS Newspaper (please specify) _________________
JobLink/ESC Indeed LinkedIn Other (please specify) ______________________
Minimum Annual Salary Requirements: $__________________________ If part-time please list hourly rate: $______________
GENERAL INFORMATION
1. Have you ever been employed with Martin Community College? Yes No
If yes, what position and when?_______________________________________________
2. Are you a retiree with the State of North Carolina (TSERS Retirement System) Yes No
3. Are you related by blood or marriage to any employee of Martin Community College? Yes No
If yes, give name and relationship: ____________________________________________
4. We are generally unable to provide sponsorship for employment visas.
Are you authorized to work in the United States? Yes No
Do you now or will you in the future require employer sponsorship? Yes No
✔
EDUCATION
Note: Unofficial transcripts must be submitted with application. If position is offered official transcripts will be required.
Education
Name & Location
Dates Attended
Graduate
(Y/N)
Degree
Received
Year
Received
High School
Diploma/GED
Yes
No
Associates
Degree
Yes
No
Bachelor’s
Degree
Yes
No
Master’s
Degree
Yes
No
Other
Graduate/
Professional
Yes
No
PROFESSIONAL INVOLVEMENT
List any professional certifications, licenses and any other training/credentials/honors related to the position you are applying for.
ADDITIONAL INFORMATION
Please list any other pertinent information related to the position for which you are applying.
REFERENCES
Please list 3 professional references who have first-hand knowledge of your qualifications for the position for which you are applying.
1. ________________________________________________________________________________________________________________
(Name) (Relationship to Applicant) (Contact Number) (Email)
2. ________________________________________________________________________________________________________________
(Name) (Relationship to Applicant) (Contact Number) (Email)
3. ________________________________________________________________________________________________________________
(Name) (Relationship to Applicant) (Contact Number) (Email)
EMPLOYMENT HISTORY
IMPORTANT: Please fill out work history completely, attach additional pages if necessary. Beginning with your last/current employment, include
any paid/unpaid experience. Resumes/vitae are not accepted as a substitute for the application work history. Salary calculations are based on work
experience listed on the application.
A. Current or Most Recent Employment
Employer:________________________________________________ Address:_______________________________________________________
Position: _________________________________________________ Supervisor Name & Title: _________________________________________
Telephone Number: ______________________ Starting Salary: $________________ Ending Salary $: ________________ No. Supervised _______
Duties:
Reason for leaving: ________________________________________________________________ May we contact employer? Yes No
B. Previous Employment
Employer:________________________________________________ Address:_______________________________________________________
Position: _________________________________________________ Supervisor Name & Title: _________________________________________
Telephone Number: ______________________ Starting Salary: $________________ Ending Salary $: ________________ No. Supervised _______
Duties:
Reason for leaving: ________________________________________________________________ May we contact employer? Yes No
C. Previous Employment
Employer:________________________________________________ Address:_______________________________________________________
Position: _________________________________________________ Supervisor Name & Title: _________________________________________
Telephone Number: ______________________ Starting Salary: $________________ Ending Salary $: ________________ No. Supervised _______
Duties:
Reason for leaving: ________________________________________________________________ May we contact employer? Yes No
Date Employed (mo/yr):
Date Separated (mo/yr):
Full-Time
Years
Months
Part-Time
Years
Months
If Part-Time, # of hours
Worked per week:
Date Employed (mo/yr):
Date Separated (mo/yr):
Full-Time
Years
Months
Part-Time
Years
Months
If Part-Time, # of hours
Worked per week:
Date Employed (mo/yr):
Date Separated (mo/yr):
Full-Time
Years
Months
Part-Time
Years
Months
If Part-Time, # of hours
Worked per week:
CERTIFICATION
Please read carefully before signing.
I certify that all information on this application is correct. I authorize any agent or employee of the College to verify this information. Such reference
calls may include persons other than those that I have listed as references in my application materials. I will hold neither the inquiring
party/organization nor the responding party/organization liable for information exchanged regarding the execution of my former employment. I
understand that any information released by my prior employers will be held in strictest confidence, that it will be viewed only by those involved in
the hiring decision, and that I waive any rights to see this information.
I certify to the best of my knowledge, the information given truly represents my background and experiences. I understand that if I have knowingly
misrepresented or falsified any of this information, I may be disqualified from employment considerations or dismissed from employment with
Martin Community College.
I understand that employment may be contingent upon a satisfactory background investigation of any or all of the following records: criminal, motor
vehicle, credit, reference checks, and/or drug test.
Applicant Signature: _____________________________________ Date: _______________________________
SUBMISSION OF APPLICATION
All applications must be signed and mailed or emailed with unofficial copies of academic and professional documents specified in the position’s
minimum qualification requirements, cover letter and resume, and references to:
Martin Community College
Office of Human Resources
1161 Kehukee Park Road Williamston, NC 27892
OR
Personnel@martincc.edu
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Martin Community College
Equal Opportunity Information
1161 Kehukee Park Road
Williamston, NC 27892
www.martincc.edu
Martin Community College policy prohibits discrimination on the basis of race, color, religion, national origin, sex, age or disability. It is the
College’s intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. The requested
information will not affect processing of your application. It will be used only to see how well our recruitment efforts are reaching all segments of the
population and to meet statistical requirement efforts set forth by State and Federal regulations.
This section of information is confidential and only viewed by the Office of Human Resources.
MILITARY SERIVCE (If declaring veteran’s preference, please submit DD214, Certificate of Release or Discharge, or similar form)
Have you served honorably in the Armed Forces of the United States on active duty for reason other than training? YES NO
Do you wish to declare a service-connected disability? YES NO
At the time of this application, are you the surviving spouse or dependent of a deceased veteran who died
from service-related reasons? YES NO
Do you wish to declare eligibility for veteran’s preference as the spouse of a disabled veteran? YES NO
Give dates of your (or spouse’s) qualifying active military service:
Entered: ____________________ Separated: ___________________ Branch: ____________________ Rank: ___________________
DISABILITY (A disability is any impairment which substantially limits a major life function)
Please check any that apply:
Visual Impairment/Blindness Respiratory Impairment
Hearing Impairment/Deafness Loss or Impairment of Upper and/or Lower Limbs
Cardiovascular Disorder Disabling Diseases (arthritis, diabetes, etc.)
Emotional/Mental Disorder Other (please specify): __________________________________
Neurological/Nervous System _____________________________________________________
Are you able to perform the essential functions of the position as described on the position announcement with or without reasonable
accommodation? YES NO
DEMOGRAPHIC INFORMATION
Date of Birth: _____________________________
Gender: Male Ethnicity: Native American/Alaska Native
Female Asian
Race: Hispanic/Latino Black/African-American
Non-Hispanic/Latino Hawaiian/Pacific Islander
White/Caucasian
Other
ADDITIONAL EMPLOYMENT HISTORY
D. Previous Employment
Employer:________________________________________________ Address:_______________________________________________________
Position: _________________________________________________ Supervisor Name & Title: _________________________________________
Telephone Number: ______________________ Starting Salary: $________________ Ending Salary $: ________________ No. Supervised _______
Duties:
Reason for leaving: ________________________________________________________________ May we contact employer? Yes No
E. Previous Employment
Employer:________________________________________________ Address:_______________________________________________________
Position: _________________________________________________ Supervisor Name & Title: _________________________________________
Telephone Number: ______________________ Starting Salary: $________________ Ending Salary $: ________________ No. Supervised _______
Duties:
Reason for leaving: ________________________________________________________________ May we contact employer? Yes No
F. Previous Employment
Employer:________________________________________________ Address:_______________________________________________________
Position: _________________________________________________ Supervisor Name & Title: _________________________________________
Telephone Number: ______________________ Starting Salary: $________________ Ending Salary $: ________________ No. Supervised _______
Duties:
Reason for leaving: ________________________________________________________________ May we contact employer? Yes No
Date Employed (mo/yr):
Date Separated (mo/yr):
Full-Time
Years
Months
Part-Time
Years
Months
If Part-Time, # of hours
Worked per week:
Date Employed (mo/yr):
Date Separated (mo/yr):
Full-Time
Years
Months
Part-Time
Years
Months
If Part-Time, # of hours
Worked per week:
Date Employed (mo/yr):
Date Separated (mo/yr):
Full-Time
Years
Months
Part-Time
Years
Months
If Part-Time, # of hours
Worked per week:
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Martin Community College Employment Application (Martin Community College)

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Completed 26 July 2020

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