APPLICATION FOR EMPLOYMENT

Transcription

1 APPLICATION FOR EMPLOYMENT University of Maryland University College is an equal opportunity employer. We invite and encourage applications from women, minorities, veterans, and disabled persons. POSITION APPLYING FOR CONTROL NUMBER (NOTE: We will accept only one application for each position. If applying for more than one, please complete a separate application, including position title and position number.) All applicants must also complete the Technical Skills Checklist. NAME (LAST NAME) (FIRST NAME) (MIDDLE) (OTHER NAMES USED) (STREET) (CITY) (STATE) (ZIP CODE) HOME ( ) OTHER PHONE ( ) Are you 18 years of age or older? YES NO Are you authorized to work in the United States on an unrestricted basis? YES NO (If you are hired, proof of authorization will be required.) Are you a current employee of UMUC (not a student worker)? YES NO Employee ID number Have you ever worked for the University System of Maryland? YES NO Have you ever worked for the State of Maryland? YES NO If you answered YES to either or both questions, please supply details. Do you have relatives currently employed at UMUC? YES NO If YES, please state their name(s) and department(s). Have you ever been convicted in court for other than a misdemeanor or a minor traffic violation? YES NO If YES, please explain EDUCATION INFORMATION A) List the last three schools you attended, starting with the most recent. Include the city and state. B) List number of years completed or semester hours completed. C) Indicate degree, certificate, or diploma earned. D) Indicate major or type of program. A Educational institutions B Did you graduate? C Degree, certificate, or D Major or program type (If no, semester hours completed) diploma earned May we contact your present employer at this time for a reference? YES NO If NO, please explain. If an offer of employment is made, what is the earliest date you can report to work?

2 EMPLOYMENT HISTORY Beginning with your most recent position, list the last four positions you have held (even if they are within the same organization). Please explain any gaps in employment in the comments below. Additional information and/or a résumé may be attached, but not substituted for the information requested below. NAME AND OF SUPERVISOR NAME AND OF SUPERVISOR NAME AND OF SUPERVISOR NAME AND OF SUPERVISOR

3 TECHNICAL-SKILLS CHECKLIST The information below allows you to tell us about your knowledge and skills using various programs and equipment. Please complete the information below by filling in the circle that indicates your present skill level. None Basic Intermediate Advanced SOFTWARE MS Word MS Excel MS PowerPoint MS Access MS Front Page MS Project Corel Word Perfect Netscape Communicator Adobe PageMaker Adobe PhotoShop Adobe Acrobat OPERATING SYSTEMS DOS Windows 95/98 Windows NT Windows 2000 Macintosh Unix HARDWARE AND PERIPHERALS IBM or compatible PC Macintosh Disk drive CD-ROM/DVD drive Laser Printer Scanner Modem Network Interface Card PROGRAMMING HTML Java Perl C++ Visual Basic Unix Shell Cold Fusion COBOL OTHER

4 CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION PRINT NAME SOCIAL SECURITY NUMBER I certify that the information that I have provided to University of Maryland University College (UMUC) is accurate and truthful to the best of my knowledge. I understand and agree that it is subject to verification by employees of UMUC. I authorize the persons, employers, schools, and other organizations named to provide UMUC with any relevant information that may be required to come to a decision regarding employment. I release from liability all individuals, corporations, or organizations that provide such information. I understand and agree that misrepresentation or omission of information may be cause for my not being considered for employment and that if I am employed, any false statements may result in my dismissal. I understand and agree that as a result of the Immigration Reform and Control Act of 1986, I must provide documents establishing both my identity and right to be employed in the United States within three business days of my initial date of employment. A photocopy of this signed authorization is as valid as an original signed authorization and may be used by UMUC to request the release of information authorized. I acknowledge that I have read this authorization, fully understand it, and fully and voluntarily agree to its provisions. SIGNATURE OF APPLICANT DATE Under Maryland law, an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test on examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed 100. SIGNATURE OF APPLICANT DATE HR USE ONLY HIRE DATE POSITION NUMBER GRADE TYPING TEST SCORE EXEMPT NONEXEMPT 6-01 [1-100]

5 DISCLOSURE STATEMENT COMPLETION OF THIS FORM IS VOLUNTARY The following information is requested of all applicants. It is needed to complete required government reports and will be detached and maintained separately from the rest of the application. Please complete all information. Completing this form is voluntary. This information will not affect employment or be used in the selection process. PLEASE PRINT NAME (OPTIONAL) POSITION APPLYING FOR CONTROL NUMBER APPLYING FOR EXEMPT POSITION NONEXEMPT POSITION ETHNICITY/RACE African American/Black Asian/Pacific Islander Caucasian/White (non-hispanic origin) Hispanic Native American/Indian Undeclared or unknown VETERAN STATUS Vietnam-era veteran (8/5/64 to 5/7/75) Retired veteran Disabled veteran Not applicable REFERRAL SOURCE UMUC job board Walk-in Washington Post UMUC Career Center Maryland Job Service Chronicle of Higher Education UMUC employment Web page Job fair Other Web source (name) UMUC employee Other source (name) GENDER Female Male DISABILITY Disabled Not disabled 6-01 [1-100]