Fillable P-10 APPLICATION - ACADEMIC 01-19 (Butte College)

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P-10 APPLICATION - ACADEMIC 01-19 (Butte College)

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P-10 (Rev 01/2019)
BUTTE-GLENN COMMUNITY COLLEGE DISTRICT DEPARTMENT OF HUMAN RESOURCES
APPLICATION FOR ACADEMIC AND ACADEMIC MANAGEMENT EMPLOYMENT
3536 BUTTE CAMPUS DRIVE, OROVILLE, CALIFORNIA 95965-8399
Please Print (530) 895-2400 (800) 933-8322 TDD (530) 895-2817 FAX (530) 895-2836
POSITION APPLIED FOR: ____________________________________________________ Note: An application with the words “See Resume” or similar phrase will not be accepted.
Are you interested in: ❑ Full-Time or ❑ Part-time positions?
PERSONAL INFORMATION
Name (Last, First, MI): For correspondence purposes only, please check one of the salutations: ❑ Mr. ❑ Ms. ❑ Dr.
Mailing Address:
City:
State:
Zip:
Residence Address: (Please list if different from above.)
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
May we contact you at work? ❑ Yes ❑ No
ACADEMIC ACCREDITATION
Name of Institution
(Beyond High School)
City, State
Major
Minor
Dates of Attendance
Type & Date
Degree Granted
Total Sem.
Units
Completed
Fr: Mo/Yr
To: Mo/Yr
EXPLANATION OF DEGREE IN PROGRESS
REFERENCES – Name of persons who are familiar with your previous employment experience whom we may contact if you are a finalist.
Name
Title
Business/Institution
Daytime Phone Number
P-10 (Rev 01/2019)
LIST (MOST RECENT FIRST) ALL TEACHING EXPERIENCE (Use an additional sheet, if necessary)
Employment Dates
Name of Institution or District
Mailing Address
Including Zip Code
Subjects and/or
Grades Taught
Time
Full %
Reason for Leaving
From
To
LIST (MOST RECENT FIRST) ALL ACADEMIC EXPERIENCE OTHER THAN TEACHING (i.e., COUNSELING OR ADMIN) (Use an additional sheet, if necessary)
Employment Dates
Name of Institution or District
Mailing Address
Including Zip Code
Title of Position
Time
Full %
Reason for Leaving
From
To
LIST (MOST RECENT FIRST) OTHER RELATED JOBS
Employment Dates
Name of Business
Mailing Address
Including Zip Code
Title of Position or
Nature of Work
Time
Full %
Reason for Leaving
From
To
OTHER PROFESSIONAL ACTIVITIES (Such as travel, publications, organizations, lectures) (Use an additional sheet, if necessary)
You may omit those organizations that indicate your race, religious creed, color, disability, marital status, national origin, ancestry, sex, sexual orientation or age.
Length of Service
Nature of Experience
Current Employer
If you are currently employed, may we contact your present employer? ❑ Yes ❑ No
If “NO”, please be advised that we must contact your employer should you become a finalist for the position.
PROOF OF ELIGIBILITY TO WORK IN THE UNITED STATES
Should you be offered employment can you provide proof of eligibility to work in the U.S. at Butte College? ❑ Yes ❑ No
P-10 (Rev 01/2019)
ADDITIONAL INFORMATION:
PRE-EMPLOYMENT REQUIREMENTS – PLEASE READ CAREFULLY
• Education Code § 87408.6 states that no person shall be initially employed by a community college district in an academic or classified position unless the person
has submitted to an examination within the past sixty (60) days to determine that he or she is free of active tuberculosis.
• As a condition of employment the position you are applying for may require that you provide fingerprints to the local police department. The fee charged by the
Department of Justice (DOJ) for the fingerprint report is the employee’s responsibility. If you should be offered this position and it requires fingerprinting, you will be
asked to sign a payroll deduction form which will authorize the District to deduct the fee charged by the DOJ from your first paycheck.
GENERAL: (This space is provided for any additional information which you believe will be helpful in considering your application.)
Do you have any relatives currently working at Butte College? ❑ Yes ❑ No
Name
Relationship
Department
I declare that the information in this application is true and complete to the best of my knowledge, and I authorize investigation of all statements herein recorded. I
waive and release from all liability persons and organizations reporting information required by this application. I certify that I do not advocate, nor am I a member of
any party or organization, political or otherwise, that now advocates the overthrow of the government of the United States or the State of California by force or
violence or other unlawful means. I understand that I will be subject to forfeiture of the employment process or dismissal if any statement in this application is found to
be untrue.
Signature __________________________________________________________________ Date ______________________
APPLICATION MUST BE SIGNED AND DATED
The Butte-Glenn Community College District, Oroville, California, in compliance with Titles VI and
VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972 (45 CFR86), and
Sections 503 and 504 of the Rehabilitation Act of 1973, Titles I and II of the American’s with
Disabilities Act of 1990 does not discriminate on the basis of race, color, national origin, religion,
sex, sexual orientation, or physical/mental disability or medical condition in any of its policies,
procedures, or practices; nor does the District, in compliance with the Age Discrimination in
Employment Act of 1967 and Section 402 of the Vietnam Era Veterans Readjustment Act of 1974,
discriminate against any employee or applicants for employment on the basis of age or because
they are U.S. disabled veterans or veterans of the Vietnam era. This nondiscrimination policy
covers admissions, access, and treatment in the District’s programs and activities, and application
for and treatment in District employment. In conformance with District policy and pursuant to
Executive Order 11246 and 11375, Section 503 of the Rehabilitation Act of 1973, and Section 402
of the Vietnam Era Veterans Readjustment Act of 1974, the District affirms diversity and is an
equal opportunity employer.
Inquires regarding the District’s equal opportunity policies may be directed to the Equal
Opportunity Officer, Administration Building, Office of Human Resources, Butte College, 3536
Butte Campus Drive, Oroville, CA 95965-8399 (Telephone 530-895-2400); Title IX Compliance
Officer, 530-895-2379; and Sections 503/504 Compliance Officer, Specialist/Disabled Student
Services, 530-895-3455, ADA Coordinator, 530-895-2244. In addition, inquiries may be directed to
the Director of the Office of Civil Rights, Department of Labor, Washington, D.C. 20201.
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P-10 (Rev 01/2019)
REQUIRED SUPPLEMENTAL INFORMATION
ACADEMIC AND ACADEMIC MANAGEMENT
CONFIDENTIAL
THIS SUPPLEMENTAL INFORMATION IS FOR THE USE OF THE HUMAN RESOURCES OFFICE ONLY
Please Print
Position applied for:
Social Security No.:
Name:
___________________________________________________________________________
___________________________________________________________________________
_____________________________________ ______________________________ ___
Last First MI
Have you ever been employed, attended college, or obtained a job related degree or certificate under another name? ❑ Yes ❑ No
If “YES”, please state name, where and when. ________________________________________________________________________
P-10 (Rev 01/2019)
DEPARTMENT OF HUMAN RESOURCES
Butte-Glenn Community College District
3536 Butte Campus Drive
Oroville, California 95965-8399
CONFIDENTIAL EQUAL OPPORTUNITY PROGRAM INFORMATION
(Voluntary Information)
Position Applied For: _______________________________________________________ Name: ________________________________________________
The following information is necessary in order for the Butte-Glenn Community College District to evaluate its recruitment and hiring practices and to prepare reports required by state and
federal agencies. The information you provide is strictly confidential and will not be used in any way to affect your employment status with the District. Although providing this information
is voluntary, your cooperation is greatly appreciated.
CONFIDENTIAL EQUAL OPPORTUNITY PROGRAM INFORMATION
AGE: ❑ Under age 30
❑ Age 30 but under 40
❑ Age 40 but under 50
❑ Age 50 or older
SEX: ❑ Male ❑ Female
VIETNAM ERA VETERAN: ❑ Yes ❑ No
ETHNICITY: (check one only)
❑ American Indian/Alaskan Native (origins in any of the Native American Indian
peoples of North America)
Specify tribal affiliation: ____________________________________________
❑ Asian
❑ Chinese
❑ East Indian
❑ Japanese
❑ Korean
❑ Laotian
❑ Cambodian
❑ Vietnamese
❑ Black
❑ Filipino
❑ Hispanic
❑ Mexican, Mexican-American, Chicano
❑ Central American
❑ South American
❑ Pacific Islander
❑ Guamanian
❑ Hawaiian
❑ Samoan
❑ White/Caucasian (non Hispanic)
DISABILITY/LIMITATION which (1) substantially restricts one or more major life
activity, or (2) has a record of such impairment, or (3) is regarded by others as
having such impairment. (check those applicable.)
❑ Orthopedic, Mobility, or Physical
❑ Vision (blind or partial sight)
❑ Health Impairment
❑ Psychological Disorder/Recovering Substance Abuse
❑ Specific Learning Disability
❑ Deaf
❑ Hard of Hearing
❑ Speech Impairment (not foreign accent)
❑ Acquired Brain Injury
❑ Developmental Disability (Mental Retardation)
HOW DID YOU LEARN ABOUT THIS POSITION?
❑ Advertisement (specify) ___________________________________________
❑ Chancellor’s Office Registry
❑ Community Agency (specify) _______________________________________
❑ Friend or Colleague
❑ Job Fair (location) _______________________________________________
❑ Job Line
❑ Professional Organization (specify) _________________________________
❑ Vacancy Announcement
❑ Internet (specify) ________________________________________________
❑ Other (specify) __________________________________________________
Equal Opportunity Employer
District officer responsible for discrimination complaints:
Equal Opportunity Officer (530) 895-2400 ADA Coordinator (530) 895-2244
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P-10 APPLICATION - ACADEMIC 01-19 (Butte College)

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Completed 20 July 2020

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