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Personal Information (East Tennessee State University)

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Job #: Position Title:
Personal Information
First Name: Middle Name: Last Name: Other names used:
Address: City: State: Zip Code:
Home Phone Number: Business Phone Number: Email Address: Highest Level of Education
Completed:
State in which highest degree Major field of study: State in which last job was held: Years of experience in major
was earned: field:
What is the minimum monthly Date of your availability for If hired, can you furnish proof If hired, can you furnish proof
salary you will accept? employment: that you are eligible to work in that you are 18 years of age, or
the United States? if under 18, do you have a
permit to work?
If no, please explain: Have you been employed here If yes, indicate date, department Do you have any relatives
before? and name of supervisor : working here?
If yes, give name of relative, the department in which they work, and their relationship to you :
Criminal History
Are you required to register as a sex
offender under TCA Title 40, Chapter 39,
Part 2?
Educational Institutions
Name of School: City: State: Major/ Minor Field of Study ,if
applicable:
Did you graduate? Type of Degree, if applicable:
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Type of Business: Begin Date: End Date (leave blank if still Total Years/Months:
employed):
Your Title: Duties: Most Recent/Ending Salary: Hrs/Wk:
Supervisor Name: Supervisor Phone: Supervisor Title: Number of Employees
Supervised:
Reason for Leaving: May we contact this employer?
Firm Name: Street Address: City: State:
Type of Business: Begin Date: End Date (leave blank if still Total Years/Months:
employed):
Your Title: Duties: Most Recent/Ending Salary: Hrs/Wk:
Supervisor Name: Supervisor Phone Supervisor Title: Number of Employees
Supervised:
Reason for Leaving: May we contact this employer?
References
Name of Reference: Present Address: Phone Number: Email Address:
Known how long? Your relationship to this person?
Name of Reference: Present Address: Phone Number: Email Address:
Known how long? Your relationship to this person?
Name of Reference: Present Address: Phone Number: Email Address:
Known how long? Your relationship to this person?
Additional Information
List the products you have used for word Are you licensed to practice any If yes, list Profession, License Number,
processing, spreadsheets, and Windows profession? Date and Issued By:
operating systems :
Employment Experience
Firm Name:
Street Address:
City:
State:
Agreement
I certify that the information I have given is complete, true, and correct to the best of my knowledge and belief. I further affirm that I
have not knowingly withheld any facts or circumstances in completing this application. I consent to references and former employers
being contacted regarding this application. I understand that any misrepresentation of information by me may cancel this application
or be cause for my termination in the event I am employed by the university. It is a Class A misdemeanor to misrepresent academic
credentials. (T.C.A. Sec. 49-7-133).
BY SIGNING BELOW, I certify that I have read and agree with these statements.
Applicant's Name Applicant's Signature Date
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1
VOLUNTARY EQUAL EMPLOYMENT OPPORTUNITY INFORMATION REQUEST
As part of our commitment to equal employment opportunity efforts, our institution conducts a survey of all job applicants.
Submission of this information is entirely voluntary, and its contents are confidential. We do, however, appreciate your assistance and
ask that you complete the following section.
This information will not be used to discriminate against or show preference for any application in the hiring decision.
GENDER: Male Female Not Disclosed
ETHNIC CATEGORY: Ethnicity represents social groups with a shared history, sense of identity, geography, and cultural roots,
which may occur despite racial difference.
The term “Hispanic or Latino or Spanish Origin” is defined as a person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race.
Do you consider yourself to be of Hispanic/Latino/Spanish origin? Yes No Not Disclosed
RACE CATEGORY: Race represents a population considered distinct based on physical characteristics.
Select one or more of the following racial categories to describe you:
Alaska Native – A person having origins in any of the original people of Alaska, and who maintain tribal affiliation or
community attachment.
American Indian – A person having origins in any of the original peoples of North and South America (including Central
America), and who maintain tribal affiliation or community attachment.
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
Black or African American – A person having origins in any of the Black racial groups of Africa.
Native Hawaiian and Other Pacific Islander – A person having orgins in any of the original peoples of Hawaii, Guam,
Samoa, or Other Pacific Island.
White, not of Hispanic Origin – A person having origins in any of the original people of Europe, the Middle East, or North
Africa.
2
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2017
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. For additional information, please review Form CC-305
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 Autism Bipolar disorder Post-traumatic stress disorder
(PTSD)
Deafness Cerebral palsy Major depression
Obsessive compulsive disorder
Cancer HIV/AIDS Multiple Sclerosis (MS)
Impairments requiring the use of a
Diabetes Schizophrenia Missing limbs or partially
wheelchair
missing limbs
Epilepsy Muscular dystrophy
Intellectual disability (previously
called mental retardation)
Voluntary
Self
Identification
of Disability:
Yes, I have a disability (or previously had a disability)
No, I do not have a disability
I do not wish to answer
3
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.
i
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.
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:
o 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
o 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 don't wish to answer.
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Completed 23 July 2020

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