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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
State
Zip Code
Yes
No
Full-time
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
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
Yes
No
Yes
No
Yes
No
Education
Achieved High School Diploma/GED?
Yes
No
Diploma/
Degree
Major
Class
Standing
or Grade
Point Avg.
PLEASE LIST CERTIFICATIONS, LICENSES, OR SPECIAL SKILLS AND QUALIFICATIONS YOU POSSESS (SUCH AS CPA, FOREIGN
LANGUAGE FLUENCY, COMPUTER SKILLS, ETC.)
Revised 06-12
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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
Present/Previous Employer
Starting Salary
Present/Last Salary
Yes
No
Dates of Employment
From:
To:
Previous Employer
Starting Salary
Last Salary
Dates of Employment
From:
To:
Previous Employer
Starting Salary
Last Salary
Dates of Employment
From:
To:
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
Revised 06-12
Page 2
Date____________________________________
Revised 06-12
Page 3