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Employment

Application
An Equal Opportunity Employer

If you are an applicant in need of assistance or accommodation with any part of the application/interview process (for
example: filling out the application or interview) please make your request known in advance to the Human Resources
Staff or the interviewer.
Date

Personal
Name

Last

First

Address

Middle Initial

City

Phone number where we can reach you

State

Zip Code

E-mail address (optional)

Yes

Are you currently authorized to work in the United States?

No

Full-time

If yes, are you authorized to work:

Part-time

Are you a United States citizen, a permanent resident, a temporary resident, an applicant for temporary residency, or a refugee? (circle one)
Have you ever been employed by a school within The Sullivan University System?

No
Yes If yes, when? Where?
Have you ever been convicted of any felony? If yes, describe in detail (convictions will not automatically disqualify job candidates).
No
Yes, If yes, describe details.
For what position are you applying?

Salary Expectations

Date Available

How did you become aware of the position?

Are you related to anyone employed by the organization? If yes, what is their name and what is your relationship? At what location are they employed?

Yes

No

Will you work overtime, if required?

Yes

Will you travel, if required?

No

Yes

Will you work weekends, if required?

No

Yes

No

Education
Achieved High School Diploma/GED?

Yes

(Include education currently in progress.)

No
Diploma/
Degree

Major

Class
Standing
or Grade
Point Avg.

High School / Location


Technical School or College / Location

PLEASE LIST CERTIFICATIONS, LICENSES, OR SPECIAL SKILLS AND QUALIFICATIONS YOU POSSESS (SUCH AS CPA, FOREIGN
LANGUAGE FLUENCY, COMPUTER SKILLS, ETC.)
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Employment History (Please list your previous employers, starting with the current or most recent employer)
Are you employed at present?

Yes

No

May we contact your present employer?

Present/Previous Employer

Employers Address and Phone Number

Last Supervisor/Phone Number

Reason For Leaving

Starting Salary

Your Job Title(s)

Present/Last Salary

Yes

No

Dates of Employment
From:
To:

Describe Your Duties and Responsibilities

Previous Employer

Employers Address and Phone Number

Last Supervisor/Phone Number

Reason For Leaving

Starting Salary

Your Job Title(s)

Last Salary

Dates of Employment
From:
To:

Describe Your Duties and Responsibilities

Previous Employer

Employers Address and Phone Number

Last Supervisor/Phone Number

Reason For Leaving

Starting Salary

Your Job Title(s)

Last Salary

Dates of Employment
From:
To:

Describe Your Duties and Responsibilities

References
Please provide three business references other than those listed above.
Name

Title

Phone Number

Relationship

Name

Title

Phone Number

Relationship

Name

Title

Phone Number

Relationship

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PLEASE READ THE FOLLOWING VERY CAREFULLY BEFORE SIGNING:


I agree to fully cooperate in The Sullivan University System's background investigation, and to sign any waivers or releases
that may be necessary to obtain access to relevant information. In the event that any former employer or federal, state or
local government agency will not release reference information or criminal history information directly to the employer, I
agree to personally request such information to the extent permitted by law. I hereby release my former employers, their
agents, personal references, educational institutions, any state and federal bureau from all liability for any damage
whatsoever in responding to inquiries and furnishing said information during this background investigation. I release The
Sullivan University System from and indemnify The Sullivan University System against any liability that may result from any
background investigation. My consent for any such background investigation shall remain in effect for the length of my
employment.
I acknowledge that employment in the position for which I have applied may be contingent upon successful completion of
pre-employment screening procedures such as a criminal background check and test for the presence of illegal substances.
I acknowledge that any claim or lawsuit arising out of my employment with, or my application for employment with the
Sullivan University System or any of its subsidiaries/divisions must be filed no more than six (6) months after the date of the
employment action that is the subject of the claim or lawsuit.
It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to
age, race, religion, color, sex, national origin, marital status, expunged juvenile records, pregnancy, disability, veteran status
or membership in the armed services, genetic information, or any other characteristic protected by Federal, State, or Local
Law.

Applicants Signature __________________________________

Date____________________________________

Applicants Social Security Number _______________________

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