Application for Employment (Exempt)

Name

First NameMiddle NameLast Name

Position Desired

Date of Application

MonthDayYear

Date Available for Employment

MonthDayYear

Salary Desired: $ Salaryper Year/Hour*

SSN (last 4 digits only)

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address (for mailing)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Are you legally entitled to work in the United States?

Will you now, or in the future, require sponsorship for employment visa status (e.g., H-1B visa status)?

If you are applying or an Athletic position: Have you ever been involved in past NCAA rules violations?

Educational qualifications - please list the following: 1. Colleges/universities attended, 2. Dates attended, 3. Majors/minors, 4. Date graduated, and 5. Degrees earned for each.

List in reverse order, the positions you have held, starting with your present or most recent employment. If more than one position or classification has been held with a given organization, list each position or classification as a separate period of employment.

Present or last employer:blanks*

Address:   Street Address*      City*   State*   Zip*

Immediate Supervisor:   First Name*   Last Name*

Title of Supervisor:   Supervisor Title*

Your Title:   Your Title*   Department:   Department*

Starting Salary:   Starting Salary*   per   Year/Hour*

Last or Present Salary:   Last Salary*   per   Year/Hour*

Date Employed:   Date*   Date Separated:   Date*

Total Months Employed:   Total Months*

Specific Duties:   Duties*

Reasons for Leaving:   Reasons for Leaving*

Present or last employer:blanks

Address:   Street Address   Address Line 2   City   State   Zip

Immediate Supervisor:   First Name   Last Name

Title of Supervisor:   Supervisor Title

Your Title:   Your Title   Department:   Department

Starting Salary:   Starting Salary   per   Year/Hour

Last or Present Salary:   Last Salary   per   Year/Hour

Date Employed:   Date   Date Separated:   Date

Total Months Employed:   Total Months

Specific Duties:   Duties

Reasons for Leaving:Reasons for Leaving

Special Honors and Activities

(Please list any special honors awarded you as an educator; also list church, civic, or service organizations in which you have participated. Attach additional sheets as necessary.):

List any textbooks, papers, articles, or other publications you have authored as a scholar. (Attach additional sheets as necessary):

Attach additional sheets as necessary

Please upload supporting documents here:

List below at least four prominent citizens (from your community) whom you know well and who can give information regarding your character and reputation. Please give name, occupation or profession, address and telephone number.

Name:   First Name*   Last Name*   Occupation/Profession:   Occupation*
Address:   Street Address*   Address Line 2*   City*   State*   Zip*
Phone: *   Phone Number*

Give any additional information you think would be of value concerning your qualifications for this position:

Signature

AFFIRMATIVE ACTION COMPLIANCE STATEMENT This institution, in compliance with Title VI and Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, sections 503 and 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act Amendments Act of 2008, and other applicable federal laws and regulations, and to the extent required by law, does not discriminate on the basis of race, color, national origin, sex, age, religion, genetic information, physical or mental disability, or status as a veteran in any of its policies, practices, or procedures. This includes, but is not limited to, admissions, employment, financial aid, and educational services. Inquiries concerning the application of these programs should be made to Calleb Mosburg, Dean of Student Affairs and Enrollment Management, Northwestern Oklahoma State University, 709 Oklahoma Boulevard, Alva, OK 73717, (580) 327-8415.

Please verify that you are human

Application for Employment (Exempt)

Employment Record

References