PERSONAL INFORMATION

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1 APPLICATION FOR EMPLOYMENT FORM WAYNE COMMUNITY COLLEGE P. O. Box 8002 Goldsboro, NC POSITION BEING APPLIED FOR: DATE: TYPE OF EMPLOYMENT DESIRED: Full-Time Part-Time PERSONAL INFORMATION Please Print In Ink or Type Name City State Zip Previous City State Zip Telephone. ( ) Cell. ( ) Business. ( ) Are you a Veteran of the Armed Forces of the United States? Have you retired from the State of rth Carolina employment? Date The Immigration Reform and Control Act of 1986 requires that all applicants provide evidence of identity and eligibility to work prior to employment. If selected for employment, the applicant must submit to a criminal background check and drug screening. FOR HR ONLY

2 EDUCATION School Name & Location Did You Type Major Graduate? Degree (Course of Study) High School Other Post-secondary degrees must be from institutions accredited by a regional accrediting association recognized by the United States Department of Education. Photocopies of all collegiate transcripts showing degree(s) conferred should accompany the application. Official transcripts of all collegiate work will be required prior to employment. SKILLS, INTERESTS AND ACTIVITIES List fields of work for which you are licensed, registered, or certified, giving date(s) and source(s) of issuance: Job skills: (If clerical, please indicate words per minute and word processing packages): List professional recognitions, current professional memberships, committee work, other activities, etc., that relate to your ability to perform in the position for which you are applying: Is there anything that would prevent you from performing, in a reasonable and safe manner, the activities involved in the position for which you have applied? If yes, please explain: Have you ever been convicted of a felony? If yes, state nature of offense, when where, and disposition. REFERENCES: Immediate Supervisors should be listed for all work experience within the past three years. If most recent experience was not within the past three years, please provide references from last work experience. Those named should be references qualified to provide firsthand knowledge of your ability for this position. (A) Name Phone (B) Name Phone (C) Name Phone 2

3 WORK EXPERIENCE To be prepared by all applicants. A resume may be attached as a supplement but not in lieu of this section. Fill in all blanks. Include military service if training and experience are related to position. List most recent position first. Include part-time positions. Name of Employer Title of Present or Last Position Actual Duties - describe in detail Immediate Supervisor & Telephone Number Date Employed Full-time: years Part-time years From to months months Hours per week Starting Salary Last Salary Reason for leaving or desiring a change May we communicate with this employer? YES NO Number of staff supervised Name of Employer Title of Present or Last Position Actual Duties - describe in detail Immediate Supervisor & Telephone Number Date Employed Full-time: years Part-time years From to months months Hours per week Starting Salary Last Salary Reason for leaving or desiring a change May we communicate with this employer? YES NO Number of staff supervised Name of Employer Title of Present or Last Position Actual Duties - describe in detail Immediate Supervisor & Telephone Number Date Employed Full-time: years Part-time years From to months months Hours per week Starting Salary Last Salary Reason for leaving or desiring a change May we communicate with this employer? YES NO Number of staff supervised Other Periods: State what you did in other periods not already covered. Include periods of unemployment, self-employment, part-time or temporary work. From To Employer Job Hours Full-time/ Month/Year Month/Year Title Per Week Part-time (Select one) 3

4 How were you referred to us? Have you previously applied to this college? If yes, give date Have you ever been employed by this college? If yes, state position and when? When are you available for work? Salary expected Do you have any relatives in our employ? If yes, Name Position Relationship If you were formerly identified by another name, please state this name. Add any information you would like to include In order to comply with various legal requirements, it is necessary and desirable for the following statements to appear on the application. Please read these statements carefully before affixing your signature. In accordance with 606 of Title VI of the Consumer Credit Protection Act, you are hereby advised that Wayne Community College may procure or cause to be prepared an investigative consumer report, including information as to your character, general reputation, personal characteristics and mode of living, whichever are applicable; and you are further advised of your right, within a reasonable time of this notice, to make written request of Wayne Community College for a complete and accurate disclosure of the nature and scope of the investigation requested. I declare and affirm under penalty of perjury that I am eligible to be employed in the United States. If employed by Wayne Community College, I understand and agree that the employment relationship will not be for any specified time period and may be terminated at the will of either myself or the college. I understand as a condition of employment, applicants may be tested for drug and alcohol use in accordance with Wayne Community College s Drug and Alcohol Abuse policy. I understand as a condition of employment for all Allied Health Instructor positions I must submit to a criminal background check and drug screening, as required by the primary hospital with whom the College has contracted to provide clinical training. I authorize Wayne Community College to investigate all statements in this application and to contact all references and employers as indicated on page 3. I understand that false or misleading statements in this application will be sufficient cause for termination of consideration or for dismissal if already employed. The Wayne Community College Annual Security Report is available on-line at or in hard copy through Human Resources or Student Services. SIGNATURE Applications may be mailed to: HUMAN RESOURCES WAYNE COMMUNITY COLLEGE P. O. BOX 8002 GOLDSBORO, NC WCC Mission Statement Wayne Community College (WCC) is a learning-centered, public, associate degree granting institution with an open door admissions policy. WCC is located in Goldsboro, rth Carolina and is part of the rth Carolina Community College System. Wayne Community College s mission is to meet the educational, training, and cultural needs of the communities it serves. Wayne Community College is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate degrees. Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia , , for questions about the accreditation of Wayne Community College. rvmh03/15

5 SUPPLEMENT TO APPLICATION FOR EMPLOYMENT FORM* I. Please indicate why you chose teaching as a profession, and your views on special and general education, professional organizations, academic standards, research and student activities. Date Applicant s Signature RV03/12MH

6 EMPLOYMENT PREFERENCE FOR VETERANS AND THEIR SPOUSES OR SURVIVING SPOUSES In hiring decisions, Wayne Community College will grant employment preference to veterans and their spouses or surviving spouses as defined in G.S In appreciation for their service to this State and this country during a period of war, and in recognition for the time and advantage lost toward the pursuit of a civilian career, veterans and their spouses or surviving spouses shall be granted preference in employment. The veteran must meet the minimum qualifications for the position and must be capable of performing assigned duties. In addition, the following criteria must be met: (1) A period of war includes World War I (April 16, 1917 through vember 11, 1918), World War II (December 7, 1941, through December 31, 1946), the Korean Conflict (June 27, 1950, through January 31, 1955), the period of time between January 31, 1955, and the end of the hostilities in Vietnam (May 7, 1975), or any other campaign, expedition, or engagement for which a campaign badge or medal is authorized by the United States Department of Defense. (2) Veteran means a person who served in the Armed Forces of the United States on active duty, for reasons other than training, and has been discharged under other than dishonorable conditions. (3) Eligible veteran means a. A veteran who served during a period of war; or b. The spouse of a disabled veteran ; or c. The surviving spouse or dependent of a veteran who dies on active duty during a period of war either directly or indirectly as the result of such services; or d. A veteran who suffered a disabling injury for service-related reasons during peacetime; or e. The spouse of a veteran described in subdivision (d) of this subsection; or f. The surviving spouse or dependent of a person who served in the Armed Forces of the United States on active duty, for reasons other than training, who dies for service-related reasons during peacetime. The qualified eligible veteran will be given preference when qualifications are equal to the nonveterans. The Human Resources Office will screen applications and inquires to determine if applicants meet the criteria for eligible veteran status. The DD214 Certificate and other relevant documents may be reviewed to verify eligibility for veteran s preference. The College policy on Veterans Preference will be attached to the employment application in support of General Statute RV09/10MH

7 EQUAL OPPORTUNITY INFORMATION Name: Position Applied For: Federal laws require this information State Government policy prohibits discrimination based on race, sex, color, national origin, age or disability. Sex, age or absence of disability is a bonafide occupation qualification in a small number of State jobs. The information requested below will in no way affect you as an applicant. Its sole use will be to see how well our recruitment efforts are reaching all segments of the population. Date of Birth: Sex: Male Female Vietnam Veteran: Ethnic Group: White Asian African American Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, other Spanish origin regardless of race) Other RV11/09MH

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