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Rev. 4-23-14 (North Georgia Technical College)

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Rev. 4-23-14
Page 1 of 7
APPLICATION FOR EMPLOYMENT
Submit to: North Georgia Technical College
Attention Human Resources
PO Box 65, Clarkesville, GA 30523
www.northgatech.edu
Daytime Telephone Number
E-mail Address
-
Last Name
First Name
Middle Initial
Street Address
Apartment No.
City
State
ZIP Code
County
EMPLOYMENT ELIGIBILITY: To be employed by the Technical College System of Georgia, an applicant must meet certain
State and Federal employment eligibility requirements. These include (but are not limited to) United States citizenship or
authorization to work in this country, positive rehire status if previously employed by the State, and/or no felony convictions within
established time frames (for certain positions). Please answer the following questions.
Are you a United States (US) citizen or an alien authorized
to work in the US?
YES NO
Have you ever been dismissed from any State of Georgia
government position?
YES NO
If YES, please enter/attach dates & explanation
TYPE OF WORK: Please do not submit without titles.
Specific Job Title Sought
TCSG Work Unit
North Georgia Technical College
EMPLOYMENT AVAILABILITY:
What type of employment are you interested in?
Full Time
Part Time
Temporary
All
CERTIFICATION: Read carefully before signing and dating. Unsigned applications will be returned.
I certify that all information on this application is correct. I authorize any agent or employee of the State or any referenced employer
to verify this information and to release it to anyone who may consider me for employment. I understand that intentionally providing
false information on this application or any accompanying attachments is a violation of state law and that any falsification of material
fact may disqualify me from employment. If employed before the falsification is uncovered, I understand that I may be released from
employment. I also understand that any application submitted electronically, via e-mail or similar media, are not valid unless I enter
my name in the signature field below and such action shall constitute an electronic signature.
I understand that if I am offered employment with any work unit or technical college associated with the Technical College System of
Georgia, the offer will be contingent upon the successful completion of a criminal history records check and, for certain job
categories, will also be contingent upon the successful completion of one or more of the following: a motor vehicle records check; a
credit history records check; a drug test; a medical examination; and/or, a psychological examination or other screening device for
law enforcement positions requiring certification by the Georgia Peace Officer Standards and Training Council. NOTE: I also
understand that there are certain criminal convictions and motor vehicle violations which may preclude my employment. Further
information may be found in the State Board of the Technical College System of Georgia Procedure governing Background
Investigations.
Signature
Date
Rev. 4-23-14
Page 2 of 7
WORK HISTORY:
Describe your work history below beginning with your current or most recent job. Include military and volunteer experience. If you
worked for the same employer but held different jobs describe each separately. Describe in detail the specific duties beginning with
your primary duties. If you need more space attach additional sheets which contain the same information requested in this section.
Include the number and types of employees under your supervision. Failure to give complete and detailed information regarding
each job held may result in your disqualification from employment consideration.
You may copy and add Work History pages as needed.
Current or Last Employer
Your Job Title
Address
From (Month/Year)
To (Month/Year)
Hours per week
City
State
ZIP Code
Check One:
Annual Salary
Paid Volunteer Intern
Your Supervisor’s Name & Title
May we contact Employer?
Supervisor’s Phone
YES NO
Reason for leaving
Number and types of employees you supervised:
Describe in detail your job duties and the average percent of work time you spent on each duty.
Employer
Your Job Title
Address
From (Month/Year)
To (Month/Year)
Hours per week
City
State
ZIP Code
Check One:
Annual Salary
Paid Volunteer Intern
Your Supervisor’s Name & Title
May we contact Employer?
Supervisor’s Phone
YES NO
Reason for leaving
Number and types of employees you supervised:
Describe in detail your job duties and the average percent of work time you spent on each duty.
Rev. 4-23-14
Page 3 of 7
WORK HISTORY:
Describe your work history below beginning with your current or most recent job. Include military and volunteer experience. If you
worked for the same employer but held different jobs describe each separately. Describe in detail the specific duties beginning with
your primary duties. If you need more space attach additional sheets which contain the same information requested in this section.
Include the number and types of employees under your supervision. Failure to give complete and detailed information regarding
each job held may result in your disqualification from employment consideration.
You may copy and add Work History pages as needed.
Employer
Your Job Title
Address
From (Month/Year)
To (Month/Year)
Hours per week
City
State
ZIP Code
Check One:
Annual Salary
Paid Volunteer Intern
Your Supervisor’s Name & Title
May we contact Employer?
Supervisor’s Phone
YES NO
Reason for leaving
Number and types of employees you supervised:
Describe in detail your job duties and the average percent of work time you spent on each duty.
Employer
Your Job Title
Address
From (Month/Year)
To (Month/Year)
Hours per week
City
State
ZIP Code
Check One:
Annual Salary
Paid Volunteer Intern
Your Supervisor’s Name & Title
May we contact Employer?
Supervisor’s Phone
YES NO
Reason for leaving
Number and types of employees you supervised:
Describe in detail your job duties and the average percent of work time you spent on each duty.
Rev. 4-23-14
Page 4 of 7
WORK HISTORY:
Describe your work history below beginning with your current or most recent job. Include military and volunteer experience. If you
worked for the same employer but held different jobs describe each separately. Describe in detail the specific duties beginning with
your primary duties. If you need more space attach additional sheets which contain the same information requested in this section.
Include the number and types of employees under your supervision. Failure to give complete and detailed information regarding
each job held may result in your disqualification from employment consideration.
You may copy and add Work History pages as needed.
Employer
Your Job Title
Address
From (Month/Year)
To (Month/Year)
Hours per week
City
State
ZIP Code
Check One:
Annual Salary
Paid Volunteer Intern
Your Supervisor’s Name & Title
May we contact Employer?
Supervisor’s Phone
YES NO
Reason for leaving
Number and types of employees you supervised:
Describe in detail your job duties and the average percent of work time you spent on each duty.
Employer
Your Job Title
Address
From (Month/Year)
To (Month/Year)
Hours per week
City
State
ZIP Code
Check One:
Annual Salary
Paid Volunteer Intern
Your Supervisor’s Name & Title
May we contact Employer?
Supervisor’s Phone
YES NO
Reason for leaving
Number and types of employees you supervised:
Describe in detail your job duties and the average percent of work time you spent on each duty.
Rev. 4-23-14
Page 5 of 7
EDUCATION:
High School Graduate or GED?
Technical/Business School
No. of Months
Field of Study
YES NO
LIST ALL COLLEGES ATTENDED, DEGREE(S) OBTAINED AND COURSEWORK HOURS EARNED:
Name of College/University Attended
Degree Earned
Major
Minor
# Hours
Degree
YES NO
YES NO
YES NO
YES NO
YES NO
GEORGIA LICENSES AND CERTIFICATIONS:
Type of License/Certificate
Specialization/Endorsements
License/Certificate Number
Expiration (Mo/Yr)
Commercial Driver’s License (CDL)
Class: A B C
Other:
Employment of Relatives:
Do you have relatives employed by the Technical College System of Georgia (TCSG)?
YES NO
If YES:
Relative’s name:
Relationship:
Relative’s TCSG system office work unit or technical college:
Other Employment:
Do you currently work for another State of Georgia Agency/Department in a full-time or part-time capacity?
YES NO
If YES:
Name of agency/department and position held:
Do you currently work full-time or part-time in the TCSG system office or for a member technical college?
YES NO
If YES:
Name of TCSG system office work unit or technical college:
Retirees:
Are you currently receiving retirement benefits from the State of Georgia (i.e. TRS, ERS, PSERS, LRS, or JRS)?
YES NO
Accommodations for Applicants with Disabilities:
Do you require special examination accommodations because of a disability? If so, please attach a note to this application asking us
to telephone you in order to make arrangements. Prior arrangements are necessary in order to receive an accommodation for testing
or an interview. You must (1) notify the North Georgia Technical College HR office that you need an examination accommodation
PRIOR to the test or interview, (2) have the accommodation authorized BEFORE being tested or interviewed, and (3) provide
documentation to show the need for the accommodation (if requested by North Georgia Technical College).
Veteran’s Preference:
Preference will be given to veterans and other eligible persons as identified in State Personnel Board Rule 18, Paragraph 18.200,
provided the individual’s qualifications for the job he/she has applied for are equivalent to the most suitable non-veteran applicant for
that same job. Preference does not apply in situations involving a promotion, demotion, or transfer to a different job.
VETERAN: DD214 showing dates of service & type
of discharge
DECEASED VETERAN’S SPOUSE: DD214; marriage
certificate; veteran’s death certificate or casualty report
DISABLED VETERAN: DD214; certificate of
service-connected disability (at least 10%) from the
VA dated within the last 6 months
DISABLED VETERAN’S SPOUSE: DD214; marriage certificate;
disabled veteran’s documents dated within last 6 months
(veteran must have 100% disability)
Rev. 4-23-14
Page 6 of 7
Equal Employment Opportunity Monitoring Information:
The Technical College System of Georgia and its constituent Technical Colleges do not discriminate on the basis of race, color,
national or ethnic origin, gender, religion, disability, age, political affiliation or belief, veteran or citizenship status (except in those
special circumstances permitted or mandated by law). This nondiscrimination policy encompasses the operation of all educational
programs and activities, including admissions policies, scholarship and loan programs, athletic and other Technical College System
and Technical College administered programs, including any Workforce Investment Act of 1998 (WIA) Title I financed programs. It
also encompasses the employment of personnel and contracting for goods and services. The Technical College System and
Technical Colleges shall promote the realization of equal opportunity through a positive continuing program of specific practices
designed to ensure the full realization of equal opportunity.
Pursuant to these regulations, the following North Georgia Technical College employee(s) are designated to ensure compliance and
to coordinate and process any grievances therein:
Title IX Coordinator
Dr. Michael King
North Georgia Technical College
1500 HWY 197 N., P.O. Box 65
Clarkesville, GA 30523
Tel: 706-754-7711
Section 504 Coordinator
Ms. Kay Morgan
North Georgia Technical College
1500 HWY 197 N., P.O. Box 65
Clarkesville, GA 30523
Tel: 706-754-7828
Equal Employment Opportunity Self-Identification:
North Georgia Technical College complies with all government regulations. In an effort to comply with requirements regarding
government recordkeeping, reporting, and other legal obligations, we ask for your willful participation in providing the information
below. This portion of the application is completely voluntary and failure to complete this section will not subject one to any adverse
actions.
Please check if you do not wish to self-identify Ethnic Origin and/or Gender.
Ethnic Origin: Are you of Hispanic/Latino origin?
YES NO
If “No” please check all races that apply.
1) American Indian or Alaskan Native
2) Asian
3) Black or African American
4) Native Hawaiian or Other Pacific Islander
5) White
6) Two or more races
Gender:
Male
Female
This institution is an equal opportunity provider and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program
Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You
may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture,
Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.
Rev. 4-23-14
Page 7 of 7
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.
1
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.
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 wheelchair
Diabetes
Schizophrenia
Missing limbs or partially missing limbs
Intellectual disability (previously called mental
retardation)
Epilepsy
Muscular dystrophy
Please check one of the boxes below:
YES, I HAVE A DISABILITY (or have previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER
Your Name
Today’s Date
Reasonable Accommodation
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.
1
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.
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Completed 25 July 2020

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