APPLICATION FOR FACULTY DIVERSITY INTERNSHIP PROGRAM
AN AFFIRMATIVE ACTION, EQUAL OPPORTUNITY INSTITUTION
PERSONAL INFORMATION
First
Middle
Preferred Name
Previous name(s) used
Address
City
State
Last
ZIP
Phone Home
Work
Message phone
Email
I hereby certify that this application and resume contain no misrepresentations or falsifications and are
complete to the best of my knowledge and belief. I understand that misrepresentation or omission of facts
called for in this application is cause for cancellation of the application and/or dismissal from the program. I
authorize Portland Community College to make any necessary and appropriate investigations to verify the
information contained herein.
Date ____________________ Applicant Initials_______________________________________________
Complete below even if it appears on resume’ or curriculum vitae.
High School Diploma/GED Certificate
Yes
No
Colleges and Universities Attended
Name of Institution
Location
Major
Minor
Degree/Certificate
Granted
SPECIAL TRAINING/SKILLS: List any special training, licenses, certificates, machine skills, office
equipment, or other special skills you may have that are pertinent to the position to which you are
applying.
EMAIL COMPLETED APPLICATIONS TO:
elisabeth.davidson@pcc.edu
EMPLOYMENT HISTORY: List below your experience, beginning with your present or most recent position. Describe each
position separately. Give special attention to experience relating to the internship. Attach additional sheets if necessary.
Complete below even if it appears on resume’ or curriculum vitae.
May Portland Community College contact your past/present
employers?
If no,
identify:
1) Last or Present Employer, Internship, Volunteer
Experience, or Teaching Assistant position
Phone
Address
City
Yes
No
Job Title
State
ZIP
Reason for Leaving
Name of Supervisor
Date Started
Mo
Yr
Date Ended
Mo
Yr
Hrs/Wk
Full Time
Part Time
Describe Specific Duties:
2) Last or Present Employer, Internship, Volunteer
Experience, or Teaching Assistant position
Phone
Address
City
Job Title
State
ZIP
Reason for Leaving
Name of Supervisor
Date Started
Mo
Yr
Date Ended
Mo
Yr
Hrs/Wk
Full Time
Part Time
Describe Specific Duties:
3) Last or Present Employer, Internship, Volunteer
Experience, or Teaching Assistant position
Phone
Address
City
Job Title
State
ZIP
Reason for Leaving
Name of Supervisor
Describe Specific Duties:
Date Started
Mo
Yr
Date Ended
Mo
Yr
Hrs/Wk
Full Time
Part Time
4) Last or Present Employer, Internship, Volunteer
Experience, or Teaching Assistant position
Phone
Address
City
Job Title
State
ZIP
Reason for Leaving
Name of Supervisor
Date Started
Mo
Yr
Date Ended
Mo
Yr
Hrs/Wk
Full Time
Part Time
Describe Specific Duties:
5) Last or Present Employer, Internship, Volunteer
Experience, or Teaching Assistant position
Phone
Address
City
Job Title
State
ZIP
Reason for Leaving
Name of Supervisor
Date Started
Mo
Yr
Date Ended
Mo
Yr
Hrs/Wk
Full Time
Part Time
Describe Specific Duties:
Name
A minimum of two academic or non-employment references
Position
Address
City
State
Phone
1.
2.
3.
NOTES:
 Email your application and other materials as attachments to
elisabeth.davidson@pcc.edu


Keep a copy of your application for interviews. Copies will not be provided.
For best consideration, all application materials should be received at the above
email address by 5:00 p.m. on March 2, 2016. The deadline for all applications is 5:00
p.m. on March 16, 2016.
EQUAL EMPLOYMENT OPPORTUNITY DATA SHEET
Portland Community College is required by the Federal government to maintain demographic
information about its employees and applicants.
ETHNIC GROUP check any that apply
Hispanic or Latino
[
] All persons of Mexican, Puerto Rican, Cuban, Central or South American or other
Spanish or Portuguese culture or origin, regardless of race.
Race Category: If you have identified yourself as Hispanic or Latino, you are not required to
select an additional category.
[
] American Indian, Native American, or Alaskan Native
All persons having origins in any of the original peoples of North America, Central
America, and South America and who maintains tribal affiliation or community
attachment.
[
] Asian
All persons having origins in any of the original peoples of the Far East, Southeast
Asia, or the Indian subcontinent , including, for example, Cambodia, China, India,
Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
[
] Black or African American
All persons having origins in any of the black racial groups of Africa.
[
] Native Hawaiian or Other Pacific Islander
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.
[
] White
All persons having origin in any of the original peoples of Europe, North Africa, or the
Middle East.
Gender
Age
[
]
Female
[
] Under 40
[
]
Male
[
] 40 plus
Additional comments
______________________________________________________________
______________________________________________________________
Faculty Diversity Internship Program
Supplemental Questions
Please provide typed written responses to the following statements.
(Not to exceed three pages).
1. Why do you want to teach at Portland Community College?
2. What is your philosophy for teaching?
3. Based upon your educational and experiential background, what do you want to teach
at Portland Community College and how, according to the Minimum Instructor Qualifications
are you qualified to do so?
4. What unique experiences have you had professionally, personally, or in training, that
prepared you to be a good candidate for the Faculty Diversity Internship Program in College
Teaching?
Required Application Materials:
Only fully complete application materials will receive full consideration.
Application materials:
 PCC Faculty Diversity Internship Program Application
 Cover letter (not to exceed two pages) detailing applicant’s qualifications for the internship
program
 Resume or Curriculum Vitae
 Unofficial graduate transcript (official transcript required at time of acceptance into the
program)
 Answers to Supplemental Questions (not to exceed three pages)
 Send all items as attachments via email to elisabeth.davidson@pcc.edu by 5pm Wednesday,
March 16th, 2016
For more information, please contact Elisabeth Davidson in the Office of Equity and Inclusion at
971.722.5840 or by email at elisabeth.davidson@pcc.edu
Elisabeth Garcia Davidson, Faculty Diversity Internship Coordinator
Office of Equity and Inclusion
Portland Community College District
Downtown Center, Room 300
722 SW 2nd Avenue
Portland, OR 97204