Classified and Hourly Positions
Application for Employment
Pierce College District
HUMAN RESOURCES
9401 Farwest Drive SW.
Lakewood, WA 98498-1999
WEB: http://www.pierce.ctc.edu
Email: humanres@pierce.ctc.edu
Telephone: (253) 964-6579
Fax:
(253) 912-3638
TDD:
(253) 964-6228
This application must be filled out completely, typed or printed in blue or black ink, and signed.
Position for which you are applying:
Type of employment you are willing to accept:
Full-time
Part-time
PERSONAL DATA
Name:
Recruitment Number:
Shifts:
Day
Hourly
Afternoon/Evening
Night
Former name(s) under which you have been employed:
Street Address:
City, State, Zip Code:
Home Telephone: (
)
Other Contact:
Telephone: (
E-mail Address:
)
Are you currently a permanent classified employee of a state agency or public higher
education institution in Washington?
Yes
No
EDUCATION
Have you graduated from high school or received a GED certificate?
College or University
City, State
Yes
From
Mo/Yr
Can you provide proof of United States citizenship or authorization to work in the United
States?
Yes
No
No
To
Mo/Yr
Total Credits
Earned
Sem
Qtr
Sem
Qtr
Sem
Qtr
Degree, Diploma or
Certificate
Major or Subject
Taken
Technical, trade, business or
other school
City, State
From
Mo/Yr
To
Mo/Yr
Total Credits
Earned
Sem
Degree, Diploma or
Certificate
Major or Subject
Taken
Qtr
Sem
Qtr
Sem
Qtr
SKILLS: List office, computer and trade skills, or other skills pertinent to the position for which you are applying.
LICENSES, PERMITS AND CERTIFICATES: (Relevant to position)
EMPLOYMENT HISTORY
List most recent experience first. Include military service experience and non-paid experience, which is related to the job for which you are applying. Submitting a résumé is optional.
A résumé cannot be used to replace the Employment History portion of this application form.
Employer:
Job Title:
Street Address:
Duties:
City/State/Zip:
Immediate Supervisor:
Telephone: (
)
E-mail:
Reason(s) for Leaving
Dates of Employment: From: (mo/yr)
To: (mo/yr)
Salary:
Hours per week:
Employer:
Job Title:
Street Address:
Duties:
City/State/Zip:
Immediate Supervisor:
Telephone: (
)
Dates of Employment: From: (mo/yr)
To: (mo/yr)
E-mail:
Reason(s) for Leaving
Salary:
Hours per week:
Employer:
Job Title:
Street Address:
Duties:
City/State/Zip :
Immediate Supervisor:
Telephone: (
)
E-mail:
Reason(s) for Leaving
Dates of Employment: From: (mo/yr)
To: (mo/yr)
Salary:
Hours per week:
NOTE: If you need to list more than three employers, please attach additional sheets.
PROFESSIONAL REFERENCES – Include those work colleagues who have first hand knowledge of your skills and abilities. (Do not include personal friends or relatives)
Name:
Telephone Number: (
)
Official Position & Employer:
Name:
Telephone Number: (
)
Telephone Number: (
)
Official Position & Employer:
Name:
Official Position & Employer:
NOTE: If you need to list more than three professional references, please attach additional sheets.
VETERAN'S PREFERENCE
Veterans, widows/widowers of veterans and spouses of veterans who wish to receive veteran’s preference must complete and attach the "Request for Veteran's Preference”
form when applying for classified positions.
PLEASE READ CAREFULLY
An applicant’s criminal conviction record as it relates to job performance may be considered as allowed under state law. Once a conditional offer of employment has been made to
an applicant, the College may perform background checks.
Have you been convicted of a felony within the last ten years?
Yes
No
If yes, please describe:
A conviction record will not automatically disqualify you for employment unless such record would reasonably affect your fitness for the position for which you have applied.
APPLICANT'S CERTIFICATION AND AGREEMENT
Please read carefully
I hereby authorize Pierce College to make inquiries regarding my education, work experience and references. I hereby release all parties and persons associated with
any such inquiries from liability in connection with furnishing this information.
I understand that should my position include security clearances, significant money handling, unsupervised access to children under the age of 16, developmentally disabled
persons, vulnerable adults, or if I am provided with multiple key / card access to buildings, classes and facilities, I will consent to a background investigation to check information
contained in or related to my application, including records of law enforcement agencies.
If I am offered employment, I understand that employment will be on a conditional basis pending completion of the background check. I understand that should investigation
disclose misrepresentation or omission, such disclosure will constitute grounds for withdrawal of employment offer, rejection of application, or dismissal.
I certify that the information provided in this application including attached documents is true, correct and complete to the best of my knowledge. I understand that
consideration of this application and the continuation of any employment gained, depend upon the true and accurate representation of the facts as stated or implied
in this application.
Signature _________________________________________________________________
Date __________________________________
NOTE: If submitting your application form by email and you are selected for an interview, you will be required to sign your application at the time of the interview.
It is the policy of Pierce College to provide equal employment opportunity in all terms and conditions of employment for all persons without regard to race, color,
creed, religion, national origin, sex, sexual orientation, age, marital status, presence of sensory, mental or physical disability, or disabled or Vietnam-era veteran.
An Equal Opportunity/Affirmative Action Employer
Revised 8/03/2007
PIERCE COLLEGE
VOLUNTARY INFORMATION
Position Applied For:
Name:
Date:
The college requests that you provide the following information.
REFERRAL SOURCE: How were you referred to Pierce College?
Newspaper in print: (which)
___________________________________
Internet Source (which one?):
_______________________________________________
Job Fair (which one?)
_____________________________________________________
State Employment Office
Public Agency (which one?)
Other source: (specify)
AFFIRMATIVE ACTION:
Pierce College is committed to an Affirmative Action Program which provides for the recruitment of women, persons of color, individuals with disability, aged, special disabled veterans and veterans of the Vietnam era, in
job categories in which they may be under-represented. To implement this program more successfully. Completion of this section is completely VOLUNTARY, will be considered confidential and will be filed separately
from the main application form. Refusal to provide any information requested on this form will not in any way subject you to any adverse treatment.
Birthdate:
_______________
Sex:
Male
Female
Which race do you consider yourself to be? (Note: computer system accepts only one race code)
White (800)
Black or African-American (870)
Korean (612)
American Indian (Print name of enrolled or principal tribe)
__________________________________________________________
Eskimo (935)
Aleut (941)
Asian Indian (600)
Vietnamese (619)
Guamanian (660)
Chinese (605)
Filipino (608)
Hawaiian (653)
Samoan (655)
Japanese (611)
Other Asian or Pacific Islander (Please specify)
_____________________________
Other Race (Please specify)
________________________________________________________________________________
Multi-Racial (If you have indicated multi-racial, please choose one preference for Affirmative Action purposes)
__________________________
Are you or are you not of Spanish/Hispanic origin? (Note: computer system accepts only one code)
No, not Spanish/Hispanic (999)
Yes, Puerto Rican (727)
Yes, Cuban (709)
Yes, Mexican, Mexican-Am., Chicano (722)
Yes, other Spanish/Hispanic (Please specify)
Do you have a disability? “Disability” means the presence of a sensory, mental, or physical impairment that: is medically cognizable or diagnosable; exists as a record or history; is perceived to exist whether or not it exists in
fact.
Yes
No
If you are a VETERAN, please check all boxes that apply:
Veteran Status:
Special Disabled Veteran
Definition: a person entitled to disability compensation under laws administered by the US Dept. of Veteran Affairs for disability rated at 30% or more, or rated at 10% or 20% if
determined to have a serious employment handicap, or a person whose discharge or release from active duty was for a service-connected disability.
Vietnam-Era Veteran
Definition: a person who served on active duty for a period of more than 180 days, any part of which occurred (1) between February 28, 1961 and May 7, 1975 in the case of a
veteran who served in the Republic of Vietnam, or (2) between August 5, 1964 and May 7, 1975 in all other cases AND was discharged or released from duty with other than a
dishonorable discharge. The term also refers to a person who was discharged or released from active duty for a service-connected disability if any part of such active duty was
performed in the Republic of Vietnam during the same time periods listed above.
Other Veteran
Definition: a person who served on active duty during a war, OR served in a campaign or expedition for which a campaign badge, service medal or an expeditionary medal has
been awarded. To identify the campaigns and expeditions that meet this criterion, see the listing on the reverse side of this page.
Newly Separated Veteran
Definition: a veteran who has served on active duty in the U.S. Military, guard, naval or air service and who has been discharged or released within the last year from the date of
this application.
Revised 7/25/2007
CAMPAIGN/EXPEDITION
Campaign or Service Medals
American Defense Service
Army Occupation of Austria
Army Occupation of Berlin
Army Occupation of Germany
Army Occupation of Japan
China Service
China Service Medal (Extended)
Korean Service
Navy Occupation of Trieste
Navy Occupation of Austria
Navy Occupation of Berlin
Navy Units of the Sixth Fleet
SW Asia Service Medal (Desert Shield/Storm)
Berlin
Bosnia and Herzegovina (Joint Endeavor)
Bosnia and Herzegovina (Joint Guard)
Cambodia
Cambodia Evacuation (Eagle Pull)
Congo
Congo
Cuba
Dominican Republic
El Salvador
Grenada (Urgent Fury)
Haiti (Uphold Democracy)
Iraq (Northern Watch)
Korea
Laos
Lebanon
Lebanon
Libyan Area (Eldorado Canyon)
Mayaquez Operation
Panama (Just Cause)
Persian Gulf (Earnest Will)
Persian Gulf
Persian Gulf (Southern Watch) or Interception Operation
Persian Gulf (Vigilant Sentinel)
Quemoy and Matsu Islands
Somalia (Restore Hope)
Taiwan Straits
Thailand
Vietnam and Thailand
Vietnam Evacuation
Cuba
Indian Ocean/Iran
Iranian/Yemen/Indian Ocean
Lebanon
Liberia (Sharp Edge)
Libyan Area
Panama
Panama
Persian Gulf
Rwanda (Distant Runner)
Thailand
Start
9/8/39
5/9/45
5/9/45
5/9/45
9/3/45
7/7/37
9/2/45
6/27/50
5/9/45
5/8/45
5/8/45
5/9/45
8/2/90
8/14/61
11/20/95
12/20/96
3/29/73
4/11/75
7/14/60
11/23/64
10/24/62
4/28/65
1/1/81
10/23/83
9/16/94
1/1/97
10/1/66
4/19/61
7/1/58
6/1/83
4/12/86
5/15/75
12/20/89
7/24/87
8/2/90
12/1/95
12/1/95
8/23/58
12/5/92
8/23/58
5/16/62
7/1/58
4/29/75
1/3/61
11/21/79
12/8/78
8/20/82
8/5/90
1/20/86
4/1/80
2/1/90
2/1/87
4/7/94
5/16/62
DATES
End
Army
12/7/41
7/27/55
10/2/90
5/5/55
4/27/52
9/7/39
4/1/57
7/27/54
10/25/54
10/25/55
10/2/90
10/25/55
11/2/95
6/1/63
12/20/96
Present
8/15/73
4/13/75
9/1/62
11/27/64
6/1/63
9/21/66
2/1/92
11/21/83
3/31/95
Present
6/30/74
10/7/62
11/1/58
12/1/87
4/17/86
5/15/75
1/31/90
8/1/90
1/2/92
Present
2/15/97
6/1/63
3/31/95
1/1/59
8/10/62
7/3/65
4/30/75
10/23/62
10/20/81
6/6/79
5/31/83
2/21/91
6/27/86
12/19/86
6/13/90
7/23/87
4/18/94
8/10/62
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ORGANIZATIONS PARTICIPATING
Navy
Air Force
X
--X
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Marine Corp
X
--X
--X
X
--X
X
--X
--X
X
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X
Coast Guard
X
--X
X
X
----X
X
------X
X
X
X
X
X
X
X
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