This is a Secure Form


P.O. Box 126, Polkton, N.C. 28135, Phone 704-272-5330, Fax 704-272-5336

This application must be completed in its entirety for you to be considered for a position at South Piedmont Community College. Evidence of your meeting the minimum qualifications must be clearly stated on this application in order for you to be considered for employment with the college. Information contained in a resume or other attachment will not be accepted in lieu of the application, but may be included to support your application. Official transcripts will be required prior to employment.

APPLICATION FOR EMPLOYMENT
Name:
  *(Last) *(First) (Middle)

Last 4 digits of your Social Security Number: - (Optional)

*Mailing Address:
 
  *(City) *(State) *(Zip Code)
Phone Information:
  *(Home Phone) (Mobile Phone) (Business Phone)

*Email Address:

Position Applied for:

Full-time Permanent Part-time Part-time

Have you ever been employed with SPCC? Yes No

When will you be available for employment?

*Are you a military veteran? Yes No

Years of service Date entered service

Date released from service Branch of service

Honorable discharge? Yes No

What was your job in the military?

If you are not a veteran, are you a spouse of a disabled veteran; or the surviving spouse or dependent of a veteran who died on active duty? Yes No

Is there any reason known to you why you might be unable to perform consistently and promptly any of the job duties? Yes No

Have you ever been discharged or asked to resign from a position? Yes No

If your answer to either of the last two questions was "Yes," please explain:

Are you a citizen of the US? Yes No

If you are not a US citizen do you have the legal right to work in the US? Yes No

(Proof of citizenship or immigration status will be required upon employment)
Explain:

*Have you ever been convicted of a misdemeanor or a felony? Yes No

If yes, complete the following (Minor traffic violations not included)
Date: Offense: Place:
Result:
Convictions do not automatically exclude an applicant from employment consideration. The nature of the offense will be evaluated in relation to the job for which the applicant has applied.


EDUCATIONAL RECORD
Give your complete educational history below.

Type of School
Name & Location
Dates Attended
___ to ___
Yrs. Completed Graduated Degree & Major Subject
Elementary or High School


Yes No
Year:

College or University


Yes No
Year:

Graduate or Professional


Yes No
Year:

Internship
Apprenticeship
Teaching Fellowship
Graduate Apprenticeship
Other


Yes No
Year:


Level Major Subject Area Cr. Hrs. Major Subject Area Cr. Hrs.
Undergraduate
Graduate


EMPLOYMENT RECORD
Answer questions for each period of employment, beginning with the present or most recent position. If more space is needed, enclose another sheet. A resume will not serve as a substitute.

Employer 1
Employer
Address
Phone
Name of supervisor
Title of supervisor
Your job title
Date Employed
Full Time
Part Time
Date Separated
No. of Years
No. of Years
Final Salary
   If Part time, number of hours worked per week:
Number of employees you supervised
May we contact your employer?
Yes No
Duties
Reason for Leaving


Employer 2
Employer
Address
Phone
Name of supervisor
Title of supervisor
Your job title
Date Employed
Full Time
Part Time
Date Separated
No. of Years
No. of Years
Final Salary
   If Part time, number of hours worked per week:
Number of employees you supervised
May we contact your employer?
Yes No
Duties
Reason for Leaving


Employer 3
Employer
Address
Phone
Name of supervisor
Title of supervisor
Your job title
Date Employed
Full Time
Part Time
Date Separated
No. of Years
No. of Years
Final Salary
   If Part time, number of hours worked per week:
Number of employees you supervised
May we contact your employer?
Yes No
Duties
Reason for Leaving


Employer 4
Employer
Address
Phone
Name of supervisor
Title of supervisor
Your job title
Date Employed
Full Time
Part Time
Date Separated
No. of Years
No. of Years
Final Salary
   If Part time, number of hours worked per week:
Number of employees you supervised
May we contact your employer?
Yes No
Duties
Reason for Leaving


Employer 5
Employer
Address
Phone
Name of supervisor
Title of supervisor
Your job title
Date Employed
Full Time
Part Time
Date Separated
No. of Years
No. of Years
Final Salary
   If Part time, number of hours worked per week:
Number of employees you supervised
May we contact your employer?
Yes No
Duties
Reason for Leaving


Please complete this section if applying for faculty or other professional position.
List the area(s) in which your graduate courses total 18 or more semester hours.
1. 2.
(Area) (Semester Hours) (Area) (Semester Hours)
List courses you have taught on the college level:


List fields of work for which you are licensed, registered, or certified, giving date(s) and course(s) of issuance.

Software Program Proficiency (at skill level to perform daily tasks):
Adobe Acrobat Groupwise MS PowerPoint List Others here:
Moodle MS Access MS Word
Datatel MS Excel Windows
List Hobbies, Professional Recognition, Current Professional Membership, Committee Work, Publications, Civic Activities, etc.

*(Required) Provide a statement of your philosophy of community colleges and describe your professional work style. Also, include any additional information you wish. If more space is needed, enclose another sheet. A resume will not serve as a substitute.

*How did you become aware of this vacancy? (Ex: newspaper, journal, etc.)

REFERENCES:
List persons other than relatives who are in a position to certify your character, ability, experience, and qualifications for the position.
Name:
Email:
Phone:

Name:
Email:
Phone:

Name:
Email:
Phone:

CERTIFICATE OF APPLICANT
(Please check the box if you agree. You can not submit this form unless this box if checked.)
* I hereby certify that all answers and statements in this application are true. I am aware that should an investigation disclose misrepresentation or falsification, I may be dismissed or disqualified for further employment. I understand that failure to complete any portion of this application may disqualify me from consideration for employment. I understand employment may be contingent upon a satisfactory criminal background investigation. If I am hired, I am aware of the probationary period for employees at SPCC (90 days for staff and first semester for faculty).
* May 30, 2016
Applicant's Name (Unnamed/undated applications will not be processed.) Date
An Equal Opportunity College in Education and Employment


Attach Document(s): Only .doc, .docx, .pdf files are accepted
Save resume and letter of intent (if applicable) to one file and attach here.

South Piedmont Community College
Applicant Data Form

South Piedmont Community College, in compliance with federal law, collects and maintains information on the gender, race, and ethnic background of applicants. This information is also used to evaluate the effectiveness of our equal employment opportunity program.

We would appreciate your assistance in these efforts by answering the questions below. This form will be filed separately from your application and will be used for statistical purposes only. Your cooperation is most appreciated.

Applicant's Name:
*Position Applied for: Date: May 30, 2016
*Date of Birth: Gender:
Female Male


ETHNIC ORIGIN (Check only one box)
Ethnic origin is defined by the Federal Equal Employment Opportunity Commission as follows:
White “White “ – (Not of Hispanic origin). All persons having origins in any of the original people of Europe, North Africa, or the Middle East.
Black “Black” – (Not of Hispanic origin). All persons having origins in any of the Black racial groups of Africa.
Hispanic “Hispanic” – All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
Asian or
Pacific Islander
“Asian or Pacific Islander” – All persons having Pacific origins in any of the Pacific original people of the Far Islands East, Southeast Asia, the Indian Islander Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.
American Indian “American Indian or Alaskan Native” – All Alaskan Natives or persons having Indian origins in any of the original people of North America, and who maintain cultural identification through tribal affiliation or community recognition.


HANDICAP: (A handicap is any impairment which substantially limits a major life function). This information is optional. Failure to provide it will not subject you to any adverse treatment. It will be maintained separately and confidentially.
Visual impairment/blindness
Hearing impairment/deafness
Cardiovascular disorder
Emotional/mental disorder
Nervous system/neurological disorder (epilepsy)
Respiratory impairment
Loss or impairment of upper and/or lower limbs
Disabling diseases (arthritis, diabetes, etc.)
Other (explain)
If the above button is disabled, this is because you must first agree to the "CERTIFICATE OF APPLICANT" above, by placing a check in the box.