CENTRAL STATE UNIVERSITY An Affirmative Action and an Equal Opportunity Employer

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1 Date: CENTRAL STATE UNIVERSITY An Affirmative Action and an Equal Opportunity Employer Application for Employment Return Application To: Central State University Human Resources P.O. Box 1004 Wilberforce, OH Phone (937) Fax (937) Instructions: Please print or type. Include any supplemental information that you feel would be helpful in our consideration of your qualifications. Personal Information : Last First MI (Optional) City State ZIP Phone Information: Home Work Cell Are there any additional names under which your employment records, educational records, references, and other application information may be verified? YES NO If so, list the names: Rev. 06/07 -HR Do you have a legal right to live and work within the United States? YES NO Proof of citizenship or immigration status will be required upon employment. Do you have a driver s license? YES NO If no, are you willing to secure one? YES NO Are you a former Central State University Employee? YES NO If yes, please give dates and department: Do you have a relative who is currently working at Central State University? YES NO If yes, please give their relationship to you and their department: Have you ever been convicted of a felony? YES NO If yes, please explain and include name under which you were convicted: Desired Employment Date You can begin working: Full Time Part Time Temporary Intermittent Position : : Rev 11/07 -HR

2 Education and Training High School Attended: City State High School Diploma: YES NO GED: YES NO Please list below all post high school education: of Location School or College (City, State) Graduation Date Degree Received Major Please list below any additional course work or training relevant to the position for which you are applying: Skills and Proficiencies Please list below your skills and proficiencies: Office Computer & Equipment Operating Systems Computer Languages & Software Packages Special Equipment Or Machinery Please list below any additional skills and proficiencies relevant to the position for which you are applying: Shorthand Speed w.p.m. Typing Speed w.p.m. Data Entry k.p.m. Licenses, Registrations, and Certificates Please list below all licenses, registrations and certificates: Type of License Or Certificate Driver s License Chauffeur s or Commercial License Technical Certificate Other Professional License or Certificate (e.g. RN, LPN,) Issuing State Or Agency License Number Expiration Date

3 Employment Background: Please provide all employment experience, starting with your most recent position. If more space is needed, please attach an additional sheet. From (Mo/Yr) To (Mo/Yr) From (Mo/Yr) To (Mo/Yr) From (Mo/Yr) To (Mo/Yr) From (Mo/Yr) To (Mo/Yr)

4 Professional References Please list below any professional references who can attest to your professionalism and work abilities. Address Phone Relationship to You EEO Policy: Central State University maintains a policy of non-discrimination for all employees and applicants. In compliance with federal and state laws, Central State University hires, trains, and promotes all qualified employees without unlawful discrimination on the basis of race, color, sex, age, religious creed, marital status, citizenship, national origin or disability. This policy also applies to disabled veterans of the Vietnam Era. Certification: I certify that the answers I have made to all of the questions in this application are true and complete to the best of my knowledge and belief. I understand that any misrepresentation or omission of material fact on this or any record submitted pertinent to employment will constitute grounds for immediate dismissal. I understand that if this application is not completed in its entirety, it will not be processed and I will be automatically disqualified. I understand that I am responsible for the correctness of this application. I understand and agree that this application is not a contract. I understand that a background check may be required prior to employment, and that in accordance with the Drug-Free Workplace Program, drug testing may be required. I waive all provisions of law forbidding colleges or universities which I attended, or past employers, from disclosing any information which they acquired relevant to my employment. I consent that they may disclose such information to Central State University Human Resources and/or the agency that holds the vacancy for which I am applying and to appropriate officials for recruitment purposes. I understand that any offer of employment is conditional upon proof of legal authorization to work in the United States as required by the Immigration Reform and Control Act. I certify that I have read, understand, and will adhere to the aforementioned statements. Applicant s Signature Date

5 CENTRAL STATE UNIVERSITY POLICE AND SAFETY Background Investigation Authorization and Release I authorize Central State University to conduct a background check on me. I understand that such an investigation may include information as to my character, employment, education, driving, credit, and criminal history. According to the Fair Credit Report Act, I will be notified by Central State University if employment is denied because of information obtained from a Consumer Reporting Agency. I further understand and waive my right of privacy in this pre-employment investigation. I hereby release Central State University and its agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above-mentioned information or reports. CURRENT INFORMATION First : MI: Last : City: State: Zip: Social Security Number: Date of Expiration: Drivers License Number/ State: Date of Birth: Please provide all residential addresses for the past 5 years: : : County: : : County: : : County: : : County: : : County: A copy of this authorization shall be considered as valid as the original. Applicant s Signature: Date:

6 APPLICANT SURVEY NOTE: We request the information below in order to assist our equal employment opportunity efforts. This survey is voluntary. This survey will be processed separately and the information used for statistical purposes only. Date Address City, State, Zip Position you are applying for How did you learn about this position? Newspaper Vacancy Posting CSU Bulletin Board CSU Job Line Posting Electronic/computer posting Centralized Recruitment Office Other RACE: White Persons having origins in Europe or the Middle East. Black Persons having origins in any of the black racial groups of Africa. Hispanic Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. Native American or Persons having origins in American or any of the original peoples of North Alaskan Native America, and who maintain cultural identification through tribal affiliation or community recognition. Asian/Pacific Persons having origins in the Far East, Southeast Asia, Indian Subcontinent, or the Pacific Islands. DISABILITY: Do you have a physical or mental impairment, which substantially limits one or more of your major life activities? Yes No VETERAN STATUS: Are you a veteran? Yes No Disabled Veteran Vietnam Era Veteran Desert Storm/Shield Veteran SEX Male Female DATE OF BIRTH: / / Month Day Year Rev. 06/07 -HR

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