-
EMPLOYMENT APPLICATION
To be considered for employment, you are required to complete an
application form. The offer of employment is contingent upon the
ability to provide documentation which demonstrates employment
eligibility required by the Immigration Reform and Control Act of
1986. All new employees will be required to complete an
“Employment Eligibility Verification” (Form I-9) and produce
requested documentation after employment. *Federal law requires
Pratt Community College to hire only United States citizens and
aliens authorized to work in the United States.
Please answer completely and sign the application form.
PERSONAL INFORMATION POSITION INFORMATION
Full Name_________________________________________ Application
Date________________________________
Address ___________________________________________ Position of
Interest______________________________
City, State, Zip Code_________________________________
Full-time/Part-time______________________________
Phone____________________________________________ Date
Available__________________________________
Email_____________________________________________ Anticipated
Salary_______________________________
Are you 18 years of age or older? ⃝ YES ⃝ NO
Are you willing to relocate? ⃝ YES ⃝ NO
Can you legally work in the United States and, if hired, show
proof of eligibility? ⃝ YES ⃝ NO
Have you previously been employed by Pratt Community College? ⃝
YES ⃝ NO If yes, provide the dates, positions held, and reason for
leaving.
__________________________________________________________________________________________________
Have you ever been convicted of a crime other than a minor
traffic citation? ⃝ YES ⃝ NO If yes, provide the date and
disposition. A conviction will not automatically bar you from
employment.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Are there other names under which employment and/or academic
records have been filed?
__________________________________________________________________________________________________
REFERENCES List at least 3 persons who have knowledge of your
work experience and/or education. (Do not include relatives,
personal friends or immediate supervisors listed in the employment
section.)
NAME TITLE ADDRESS PHONE
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Personnel Office
(620) 450-2226 or (620) 450-2139, fax (620) 450-2285 348 NE SR
61 Pratt, Kansas 67124
Page 1 of 5
-
EDUCATION Provide complete information for current and past
education. Begin with present or most recent college education.
Attach additional education history if necessary.
High School/GED College 1 College 2 College 3
Name
City/State
From
To
Graduate? ⃝ YES ⃝ NO ⃝ YES ⃝ NO ⃝ YES ⃝ NO ⃝ YES ⃝ NO
Degree
Major/Minor
TEACHING EXPERIENCE (for academic professionals only)
Community College ⃝ Full Time ⃝ Part Time ⃝ N/A
Four-year College or University ⃝ Full Time ⃝ Part Time ⃝
N/A
High School or Elementary ⃝ Full Time ⃝ Part Time ⃝ N/A
Other educational setting ⃝ Full Time ⃝ Part Time ⃝ N/A
If applying for a teaching position, you must provide copies of
transcripts/credentials with application.
OTHER TRAINING/CERTIFICATIONS/SKILLS
Other Specialized or Technical Training Not Listed Above.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
License, Certifications and Registrations Not Listed Above.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Other skills, abilities or qualifications relevant to this job.
Include equipment and software you can operate.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Page 2 of 5
-
EMPLOYMENT HISTORY Provide complete information for all current
and past employment. Begin with present or most recent employment.
Attach additional employment history if necessary.
Company Name________________________________
Address_______________________________________
Phone________________________________________
Supervisor_____________________________________ Position
Held___________________________________ Starting
Salary__________________________________ Final
Salary____________________________________
May we contact this employer for reference? ⃝ YES ⃝ NO If no,
explain____________________________________
Company Name________________________________
Address_______________________________________
Phone________________________________________
Supervisor_____________________________________ Position
Held___________________________________ Starting
Salary__________________________________ Final
Salary____________________________________
May we contact this employer for reference? ⃝ YES ⃝ NO If no,
explain____________________________________
Company Name________________________________
Address_______________________________________
Phone________________________________________
Supervisor_____________________________________ Position
Held___________________________________ Starting
Salary__________________________________ Final
Salary____________________________________
May we contact this employer for reference? ⃝ YES ⃝ NO If no,
explain____________________________________
From_________________________________________
To___________________________________________
Duties________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Reason for Leaving______________________________
_____________________________________________
From_________________________________________
To___________________________________________
Duties________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Reason for Leaving______________________________
_____________________________________________
From_________________________________________
To___________________________________________
Duties________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Reason for Leaving______________________________
_____________________________________________
Please explain any breaks or periods of unemployment in your
employment history:
From_____________ To _____________ Reason
________________________________________________________
From_____________ To _____________ Reason
________________________________________________________
From_____________ To _____________ Reason
________________________________________________________
Page 3 of 5
-
Pratt Community College prides itself on having a
student-centered learning environment. This requires that all
employees be focused on providing student-centered instruction and
services.
PCC’s student centered philosophy is: “The student is our
customer; he/she deserves our full time and attention”.
As a candidate for employment at PCC....
• How do you visualize the position for which you are applying
fitting into our student-centered employment philosophy?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
• If you are employed at PCC, what will you do to be
student-centered in your job performance?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
• At PCC, we view our co-workers, i.e., all college employees,
as our “internal customers” who deserve our attention and friendly
cooperation. Teamwork is a high priority. Briefly explain how and
why you would fit into this type of work environment.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
DISCLAIMER AND SIGNATURE
It is understood and agreed upon that any misrepresentation by
me in this application will be sufficient cause for cancellation of
this application and/or separation from the employer's service if I
have been employed. Furthermore, I understand that just as I am
free to resign at any time, the employer reserves the right to
terminate my employment at any time, with or without cause. I
understand that no representative of the employer has the authority
to make any assurances to the contrary. I give the employer the
right to investigate all references and to secure additional
information about me, if job related. I hereby release from
liability the employer and its representatives for seeking such
information and all other persons, corporations, or organizations
for furnishing such information. I have read, or have had read to
me, the above statements. By my signature, I understand and agree
to these provisions.
Signature_________________________________________________________Date_____________________________
Pratt Community College is an equal opportunity employer and
does not discriminate on the basis of race, color, national origin,
sex, disability, age or veteran status in its programs and
activities. Pratt Community College hires only U.S. citizens and
aliens lawfully authorized to work in the United States. If you
have any questions, please contact the Director of Personnel, Pratt
Community College, 348 NE SR 61, Pratt, KS 67124, 620.672.5641 ext.
139, Title IX/Section 504 Coordinator.
Page 4 of 5
libraryTypewritten Text
libraryTypewritten Text
libraryTypewritten Text
libraryTypewritten Text
libraryTypewritten Text
libraryTypewritten Text
libraryTypewritten Text
libraryTypewritten Text
-
PRATT COMMUNITY COLLEGE
EQUAL EMPLOYMENT OPPORTUNITY COMMISSION
INFORMATION FORM
Pratt Community College is an Equal Opportunity Employer and
does not discriminate on the basis of any characteristic protected
by Federal, state, or local law. In an effort to comply with the
requirements regarding government record keeping, reporting, and
other legal obligations, we ask that you complete the information
below and return it with your application to the Pratt Community
College Personnel Director.
Submittal of this information is completely voluntary and will
be held strictly confidential. The data provided here is NOT a part
of the official application for employment and will not affect your
opportunity for employment, or terms or conditions of employment,
if hired.
We appreciate your cooperation.
Position applying for
___________________________________________________________
Check one: □ Male □ Female Age: __________
Check one of the following Race/Ethnic Groups:
□ Caucasian □ American Indian/Alaskan Native □ Black or African
American □ Asian □ Hispanic or Latino □ Other
Check if any of the following are applicable:
□ Disabled Individual □ Disabled Veteran □ Vietnam Era Veteran □
Special Disabled Veteran □ Other Veteran Referral Source (please
identify source):
□ Advertisement in Publication
___________________________________ □ Employee Name of
Publication
□ Relative □ PCC Website □ Other website
________________________________________________
Date completed __________________________________
Page 5 of 5
Anticipated Salary: If yes provide the dates positions held and
reason for leaving: If yes provide the date and disposition A
conviction will not automatically bar you from employment 1: Are
there other names under which employment andor academic records
have been filed: NAME 1: NAME 2: NAME 3: License Certifications and
Registrations Not Listed Above 1: Other skills abilities or
qualifications relevant to this job Include equipment and software
you can operate 1: Company Name: From: To: Phone_2: Supervisor:
Position Held: Starting Salary: Final Salary: Duties 1: Reason for
Leaving 2: If no explain 1: Company Name_2: From_2: Address_2:
To_2: Phone_3: Supervisor_2: Position Held_2: Starting Salary_2:
Final Salary_2: Duties 1_2: Reason for Leaving 2_2: If no explain
1_2: Company Name_3: From_3: To_3: Address_3: Phone_4:
Supervisor_3: Position Held_3: Starting Salary_3: Duties 1_3: Final
Salary_3: Reason for Leaving 2_3: If no explain 1_3: From_4: To_4:
Reason: From_5: To_5: Reason_2: From_6: To_6: Reason_3: Date:
Position applying for: Check one: OffCaucasian: OffAmerican
IndianAlaskan Native: OffBlack or African American: OffAsian:
OffHispanic or Latino: OffAdvertisement in Publication:
OffEmployee: OffRelative: OffPCC Website: OffOther website: OffAge:
Name of Publication: undefined_2: Date completed: Full Name:
Address: Application Date: Position of Interest: FT/PT: Date
Available: City, State: Phone: Email: Text1: Address22: fill_11:
gy4: Offgy2: Offgy3: OffOther Specialized or Technical Training Not
Listed Above 1: philosophy 1: teamwork: student centered: cc1:
Off41: Offhs1: Offo1: Offfill_12: fill_13: fill_14: fill_15:
fill_16: fill_17: fill_19: fill_112: fill_113: fill_114: fill_115:
fill_116: fill_117: fill_18: fill_118: fill_119: fill_120:
fill_121: fill_122: fill_123: fill_124: fill_125: fill_126: 181:
Offr1: Offwork: Offpre1: Offcrime: Offgy1: Offref3: Offref2:
Offref1: OffOther1: OffOther2: OffOther3: OffOther4: OffOther:
OffOther5: Off
