EQUAL OPPORTUNITY/ACCESS/EMPLOYER AND
EDUCATOR
Women, Minorities, and Persons With Disabilities Are
Encouraged To Apply
EMPLOYMENT/
CERTIFICATION APPLICATION
MISSION
To enrich lives and strengthen the economy
by preparing a workforce that is skilled,
diverse and flexible.
VISION
To meet the needs of the future with
innovation and excellence.
Lakeshore Technical College does not discriminate on the basis of race,
color, creed, national origin, religion, gender, age, disability, sexual
orientation, lack of English skills, arrest or conviction record, political
affiliation, marital status, or other protected categories, in its services,
employment, programs, and/or educational programs and activities,
including but not limited to admissions, access and participation. The
College attempts to be in compliance with all federal laws including but
not limited to Title IX & Section 504.
Inquiries regarding non-discrimination policies are handled by the
Affirmative Action Officer, 1290 North Avenue, Cleveland, WI 53015,
phone 920.693.1163 or 888.468.6582, ext. 1163.
Lakeshore Technical College provides reasonable accommodations to
assist persons with disabilities to access or participate in its programs or
activities. Persons requiring accommodation to access the college’s
programs, services, and/or employment should call LTC at
920.693.8213, 888.GO TO LTC (888.468.6582), or TTY Hearing
Impaired at 920.693.8956 seven days in advance of the need.
Applications of individuals who would increase the richness of
Lakeshore Technical College’s diversity are welcome.
Thank you for completing this application form and for your interest in
employment with Lakeshore Technical College.
LAKESHORE TECHNICAL COLLEGE
Name (Last, First, Middle)
Home Phone
Alternate Phone
(
(
)
Email Address
APPLICANT INFORMATION
Address
City
Position(s) Applying For
Full Time
Part Time
)
Alternate Email Address
Are You 18 Or
Older?
Yes
No
State
Zip Code
Date
Avail
Salary
Desired
REFERENCES
Three employment supervisors are required to provide related information about your occupational experience/training.
Supervisor Name
Supervisor Title
Business Name & Address
Supervisor Telephone Number and/or Email Address
APPLICANT’S CERTIFICATION AND AGREEMENT
(READ CAREFULLY)
The information I have provided in this Application for Employment and any attachments including a resume is true, correct, and complete. False, incomplete, or misrepresented information of any kind will
be sufficient cause for my application to be rejected or, if discovered after I am employed, will be cause for immediate termination of my employment.
I understand that all employers and references may be contacted during the final stage of the selection process. Therefore, I authorize and request any present or former employer, educational institution,
law enforcement agency, or other persons having personal knowledge about me to furnish Lakeshore Technical College (LTC), and/or its agents, with any and all information in their possession regarding
me in connection with an application for employment that I have filed with LTC, including all transcripts/school records and all of my personnel records with current or prior employers. I hereby release LTC
from liability and hold harmless all persons or organizations supplying this information to LTC and/or its agents.
I understand that final employment may be contingent upon specific requirements such as successful completion of a caregiver and criminal background check, motor vehicle record check, and reference
checks. A photocopy and/or facsimile copy of this signed authorization is as effective as the original.
DATE OF APPLICATION
SIGNATURE OF APPLICANT
All sections of application must be completed. Please attach a resume for more detailed information.
EDUCATIONAL PREPARATION
IMPORTANT: Copies of transcripts of college, university, or technical school credits must be submitted as attachments by Faculty and Management applicants. Official transcripts
will be required at the time of hire.
Have you received a High School diploma or its equivalent?
Yes
No
School or Institution Name:
Name of Institution and Address
(College, Technical College, Business School, PostGraduate or Special Training)
City:
Dates
Attended
State:
Degree
Completed
Type of Degree
Total Credits
Earned
Major/Minor
Minors
Yes
No
Yes
No
Yes
No
Yes
No
LIST ANY SIGNIFICANT PROFESSIONAL LICENSE(S) YOU HAVE AND ATTACH FOR VERIFICATION
Are you fluent in speaking and/or writing any foreign language? ___ Yes ___ No
If yes, please list which foreign language(s):__________________________________________________________________
COMPUTER SKILLS
Keyboarding (speed)
wpm
Indicate types of software applications, knowledge, and proficiency:
TEACHING/TRAINING EXPERIENCE
List the most recent experience first.
(Complete for Faculty and Management positions only)
From
Mo
To
Yr
Mo
Yr
Name of School
Location
Subject(s) Taught
Full Time/Part Time
Total Hours Teaching
Full Time
Part Time
Total Hours: _________
Full Time
Part Time
Full Time
Part Time
Total Hours: _________
May we contact
this employer?
Yes
No
Yes
No
Yes
No
NON-TEACHING OCCUPATIONAL EXPERIENCE
DO include Military Service. List the most recent experience first.
From
Mo
To
Yr
Mo
Yr
Total Hours
Worked
(Accumulative)
Full Time
Part Time
Employer
Address
Phone No.
Position Title
Responsibilities
Total Hours:
_________
Full Time
Part Time
Total Hours:
_________
Full Time
Part Time
Total Hours:
_________
Full Time
Part Time
Total Hours:
_________
Full Time
Part Time
Total Hours:
_________
SIGNATURE OF APPLICANT
DA TE
PE26 06/2007
May we contact your present employer? ___Yes ___No ___Currently Unemployed
Lakeshore Technical College may occasionally share applicant information with other colleges in the Wisconsin Technical College System. Please indicate below
if you DO NOT want us to share this information.
__ I DO NOT want my applicant information shared with other colleges in the Wisconsin Technical College System.
Applicant Affirmative Action Information
LTC is an Equal Opportunity/Access/Employer and Educator
The college asks for your cooperation in completing this survey. However,
completing this survey is entirely voluntary and failure to complete it shall have
no adverse impact on the assessment for hiring or the hiring decision. The survey
data is used solely and exclusively for Equal Employment Opportunity and
Affirmative Action record keeping and reporting.
Inquiries regarding nondiscrimination policies are handled by the Affirmative Action
Officer, 1290 North Avenue, Cleveland WI 53015, phone 920.693.1163 or
888.468.6582, ext. 1163. Lakeshore Technical College provides reasonable
accommodations to assist persons with disabilities to access or participate in its
programs or activities.
Lakeshore Technical College does not discriminate on the basis of race, color, creed,
national origin, religion, gender, age, disability, sexual orientation, lack of English
skills, arrest or conviction record, political affiliation, marital status, or other protected
categories, in its services, employment, programs, and/or educational programs and
activities, including but not limited to admissions, access and participation. The
College attempts to be in compliance with all federal laws including but not limited to
Title IX & Section 504.
Persons requiring accommodation to access the college’s programs, services, and/or
employment should call LTC at 920.693.8213, 888.GO TO LTC (888.468.6582), or
TTY Hearing Impaired at 920.693.8956 seven days in advance of the need.
The college, as an employer/government subcontractor, is required to comply with
government regulations.
PLEASE PRINT
Applicant Name:
Date:
Last
Position(s) for which you are making application:
First
Middle
_____________________________________________________________________________________________________________________________ ________________
Referral Source:
Advertisement (Name of
Publication) _______________
_______________________________
Internet
___ LTC Web Page
___ Job Center of WI
___ Other Website:
Friend/Relative
______________________________
_____________________________
Placement Office or Agency
_______________________________
Survey Information:
1. Check One:
Male
Female
3. Check if the following is applicable:
Veteran
LTC Recruitment Board
Other
_____________________________
2. Ethnic Data:
Are you of Hispanic/Latino or Spanish origin: Yes ___ No___
For individuals who are non-Hispanic/Latino, please select from the listing below:
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White