Application for Employment

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

Other Required Information  

Do you have proof that you are eligible to work in the U.S.?   Yes No

Have you ever worked at ASU?   Yes No

If yes, when? :

Why did you leave?

Are you now or do you expect to be engaged in any other business or employment?:   Yes No                                                                 If yes, explain.

Have you ever been convicted of a felony?   Yes No                                                            If yes, please explain: (A record of conviction will not necessarily bar you from employment):

Has your license ever been restricted, revoked, or suspended?     Yes No                                                            If yes, please explain:

If you are applying for a position which required you to drive, please complete this section:  Type of License:  Not Applicable Operator Driver’s License No: Commercial State: Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming   Classification:  Class "A" Class "B" Class "C" Class "D"                                                            Endorsements:    "H" Hazardous Materials "P" Passenger Vehicles

Active Military Service:     Yes No                                                          Service and Branch:     Date Entered:   [None]    Date Separated:   [None]

Do you type?     Yes No

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]   

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.  

Education   

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

Employment History  

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

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]
Signature:

Applicant Identification Information (for record keeping purposes only)

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]	Referred By:
Gender:	Male Female	Applicant's Signature:
Please check box below, if applicable: Veteran of the Vietnam Era Special Disabled Veteran             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.”

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