Application for Employment

 Alcorn State University is an equal opportunity/equal employment institution. 

 

Job Applied for:   
 
Department:    
 
Name: 
Last:    
First:    
Middle:    
 
Address: 
Street Address
(P.O. Box):
   
 
City:    
State:   
Zip Code:   
 
SSN:        
Telephone Number:     Cell Number:   

 

Other Required Information  

 

Do you have proof that you are eligible to work in the U.S.?  
                                                        
 
 
Have you ever worked at ASU?  
                                                        
 
 
If yes, when? :  
Why did you leave?    

 

Are you now or do you expect to be engaged in any other business or employment?:  
                                                        
 
  

 

If yes, explain.   
  
 
Have you ever been convicted of a felony?  
                                                        
 
If yes, please explain: (A record of conviction will not necessarily bar you from employment):  
Has your license ever been restricted, revoked, or suspended?
 
 
                                                        
 
If yes, please explain:  
 
If you are applying for a position which required you to drive, please complete this section: 
Type of License:   
Classification: 
                                                        
 
Endorsements:   
                                                        
Active Military Service:    
                                                        
Service and Branch:     Date Entered:   [None] Select a Date Delete the Date  Date Separated:   [None] Select a Date Delete the Date 
Do you type?    
                                                        
 
 
 
List equipment you can operate (copier, lawnmower, etc): 
 
 
Computer Systems/software with which you are experienced (Word, Excel, etc): 
 
 

List other job-related skills you have (shorthand, dictation, etc): 
 

 

 

General Information 

 

Give exact title and grade of teaching certificate you hold:
 

List other special subjects you can teach:
 

List any special (technical) skills that you possess:
 

 

Present salary per month on a nine  twelve   month basis is: $  

Least salary per month you would accept on a nine  twelve   month basis is: $  

When could you begin work here?  [None] Select a Date Delete the Date 

Could you come for an interview? 

                                               

 

List College activities engaged in, and any honors received before or since graduation: 
 

Provide any additional information which you believe will assist in arriving at a true estimate of your qualifications. Copies of testimonials may be included: 
 

References:  

These should be persons qualified to answer concerning fitness for the position you  

seek. Include especially college presidents, directors, principals, and others under whom you have last worked.  

 

  Name  Address  Phone Number  Occupation 
1           
2           
3              

 

 

Education   

 

School  Name and Location of School  Course
of Study
 
No. of Years
Completed
 
Did you
Graduate
 
Degree
or Diploma
 
Graduate         
                                           
 
College       
                                         
 
 
College       
                                         
 
 
Junior College         
                                         
 
Business/ Trade
Technical
 
     
                                         
 
 
Other       
                                         
 
 

PLEASE HAVE SENT TO US A CERTIFIED TRANSCRIPT OF YOUR CREDITS FROM EACH SCHOOL WHICH YOU HAVE ATTENDED. 

 

 

Employment History  

 

 
 
A   
 
 
Company Name:  Telephone: 
Address:  Employed - (State Month and Year)
From:  To:  
Name of Supervisor:   Rate of Pay Per Hour/Month/Year
Start: Last: 
State job title and describe your work:
 
Reason for leaving:
 

 

 
 
B   
 
 
Company Name:  Telephone: 
Address:  Employed - (State Month and Year)
From:  To:  
Name of Supervisor:   Rate of Pay Per Hour/Month/Year
Start: Last: 
State job title and describe your work:
 
Reason for leaving:
 

 

 
 
C   
 
 
Company Name:  Telephone: 
Address:  Employed - (State Month and Year)
From:  To:  
Name of Supervisor:   Rate of Pay Per Hour/Month/Year
Start: Last: 
State job title and describe your work:
 
Reason for leaving:
 

  

 
 
D   
 
 
Company Name:  Telephone: 
Address:  Employed - (State Month and Year)
From:  To:  
Name of Supervisor:   Rate of Pay Per Hour/Month/Year
Start: Last: 
State job title and describe your work:
 
Reason for leaving:
 

  

Are you related to anyone who is currently employed at Alcorn State University? 
                                 
 
If yes, please complete information below:   
 
Name  Relationship  Department  Position 
       
        
 


Do not contact: 
We may contact the employers listed above unless you indicate those you do not want us to contact.
 

Employer:   
Number(s):    
Reason:    

 

ACKNOWLEDGMENT OF TERMS AND CONDITIONS OF APPLICATION AND AUTHORIZATION

 

This application is not to be interpreted as a contract of employment or as a promise of continued employment. I acknowledge that Alcorn State University retains the right to establish and enforce with full discretion any and all rules, regulations, and policies, I certify that all the information submitted by me on this application is true and accurate. I understand that if any false information, misrepresentation of facts, or omissions are discovered, my application may be rejected, and if I am employed, my employment may be terminated.

I authorize Alcorn State University to contact any educational institution, organization, business that I have listed on my employment application, resume, or mentioned in job interviews and obtain from them any relevant information about my job qualifications, including my performance, experience, skills, credentials, and other factors affecting my suitability for employment. I understand that I am consenting to the release of any reference related information about me held or known by my former employers, department heads, supervisors, and co-workers. In addition, I consent to the release of my information about my education, performance, experience, credentials, abilities, or work-related characteristics or traits held or known by other organizations or individuals, including schools and educational institutions, professional or business associates, friends, and acquaintances that Alcorn State University might contact in the course of conducting a reference check or background investigation of my suitability or employment.

In exchange for Alcorn State University considerations of my employment application, I agree not to file or pursue any complaints, claims, or legal actions of any kind against Alcorn State University or any of its employees or agents arising out of their efforts to obtain work-related information about me.

 

Electronic Signature Disclaimer

Alcorn State University’s department of Human Resources permits you to fill out and sign certain forms using this web page.  By printing your name below, you consent to use an electronic signature rather than a paper signature.  You understand that your electronic signature is legally binding, just as if you had signed a paper document.  Your consent to use an electronic signature applies only to the submittal of your employment application.

If you prefer to use a paper signature, you may instead complete the Electronic Employment Application, print, sign and return it to us by mail with all required documents attached.  You understand that Alcorn State’s department of Human Resources will not begin to process your request until we receive the Employment Application.
 

 

Print Name:     Date:   [None] Select a Date Delete the Date 
Signature:    

 

Applicant Identification Information (for record keeping purposes only)

 

Job Applied For:   
Department:   

 

WE WOULD APPRECIATE EACH APPLICANT VOLUNTARILY PROVIDING THE INFORMATION REQUESTED BELOW. THIS INFORMATION WILL BE USED ONLY FOR STATISTICAL ANALYSIS AND AFFIRMATIVE ACTION PURPOSES.

 

Applicant Name:    Social Security No.:   
Date:   [None] Select a Date Delete the Date  Referred By:   
Gender:   
                         
 
Applicant's Signature:   
Please check box below, if applicable:
         
 
A person who served more than 180 days of active military, naval or air service, any part of which was during the period August 5, 1964 through May 7, 1975, and who (i) was discharged or released there from with other than a dishonorable discharge, or (i) was discharged or released from active duty because of a service-connected disability, regardless of length of service during the Vietnam Era.” 
 

What is your Ethnicity? 

 

Do you consider yourself to be Hispanic/Latino?
         
Select one or more races to indicate what race you consider yourself to be: