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  Home Phone ( ) _____________________Business Phone ( ) ______________________Cell Phone ( ) _____________________  Staff Employment Application Human Resources Department3251 Panthersville RoadDecatur, GA 30034 An Associate Degree Granting College of the University System of Georgia/AA/EOE PLEASE PRINT LEGIBLY OR TYPEThis form must be completed in its entirety, without including references to an attached resume, and signed. Department ______________________________________________________ Full-time_____ Part-time _____ Date _____ / _____ / _____  Name ______________________________________________________________________________ SS# ____________________________  Last First MiddleHome Address ________________________________________________________________________________________________________  Street Address City State ZipMailing Address (if different from above) ______________________________________________________________________________________  Street Address/P.O. Box City State Zip EMPLOYMENT HISTORY  (Please begin with current or most recent employment) Employer _________________________________ Kind of Business ____________________________ Employer’s Phone Number _____________________ Your Position ____________________________________ Specific Duties____________________________________________________________________ Address _________________________________________________________________________________________________________________________ Employed From _________________ to ______________________ Total Years _______________ Months________________ Starting Salary __________________ Ending Salary _____________ Supervisor’s Name and Title ___________________________________________________________________________________________________________ Reasons for Leaving ________________________________________________________________________________________________________________ Employer _________________________________ Kind of Business ____________________________ Employer’s Phone Number _____________________ Your Position ____________________________________ Specific Duties____________________________________________________________________ Address _________________________________________________________________________________________________________________________ Employed From _________________ to ______________________ Total Years _______________ Months________________ Starting Salary __________________ Ending Salary _____________ Supervisor’s Name and Title ___________________________________________________________________________________________________________ Reasons for Leaving ________________________________________________________________________________________________________________ Employer _________________________________ Kind of Business ____________________________ Employer’s Phone Number _____________________ Your Position ____________________________________ Specific Duties____________________________________________________________________ Address _________________________________________________________________________________________________________________________ Employed From _________________ to ______________________ Total Years _______________ Months________________ Starting Salary __________________ Ending Salary _____________ Supervisor’s Name and Title ___________________________________________________________________________________________________________ Reasons for Leaving ________________________________________________________________________________________________________________  MILITARY EXPERIENCE  (Complete this section if you served in active duty in the U. S. Armed Forces)Period of Active Duty ________________________________________________ Grade/Rank at Discharge ______________________________ Branch of Service ________________________________________________Special/Technical Training ____________________________________  [ ] If you are a person with a disability and require any auxiliary aids or services, please check here and a representative will contact you regarding your requirements. Georgia Perimeter College’s annual security report includes statistics for the previous three years concerning reported crimes that occurred on campus; in certain off-campus buildings owned or controlled by Georgia Perimeter College; and on public property within, or immediately adjacent to and accessible from the campus. The report also includes institutional policies concerning campus security, such as policies concerning alcohol and drug abuse, crime prevention, the reporting of crimes, sexual assault, and other matters. You may obtain a copy of the report by contacting the Department of Human Resources or by accessing the following website: http//www.gpc.edu/gpcpd/.  Job no. 06-09-061  EducationName & Address of SchoolDates of AttendanceYear of GraduationDegreeHighest Grade CompletedHigh School8 9 10 11 12 CollegeFr So Jr Sr OtherMajor Subjects ___________________________________________________________________________________________________________ Other Special Training/Skills _________________________________________________________________________________________________ Do you type? _______________ WPM ___________________________ Computer Skills __________________________________________ List any machines you operate _______________________________________________________________________________________________ Professional or Occupational Licenses Type ______________________________ Number ________________________ Expiration Date __________________________________ Type ______________________________ Number ________________________ Expiration Date __________________________________ Type ______________________________ Number ________________________ Expiration Date __________________________________ Other Qualifications – List any pertinent qualifications not previously covered such as published work, community and civic activity, special skills, etc.(Exclude those that may disclose your gender, sexual orientation, race, color, religion, national srcin, age or disabling condition.) ________________  ________________________________________________________________________________________________________________________  GENERAL INFORMATION Are you over the age of 18? [ ] yes [ ] no If hired, can you furnish proof of age? [ ] yes [ ] noAre you eligible for employment in the United States? [ ] yes [ ] noHave you ever been employed by Georgia Perimeter (DeKalb) College? [ ] yes [ ] no If the answer is yes, give dates, department and job title: ________________________________________________________________________________________________________________________ List name and relationship of any relative employed by Georgia Perimeter College: _____________________________________________________ Are you currently employed at another University System of Georgia Institution? [ ] yes* [ ] no *If yes, give name of the institution ___________________________________ Department _______________________________ Title__________  STATEMENT OF POLICY:  Georgia Perimeter College is an affirmative action/equal opportunity employer. No person in the United States shall, on the groundsof race, color, gender, sexual orientation, religion, national srcin, age or disability be excluded from employment or participation in, be denied the benefits of, or other-wise be subjected to discrimination under any program of employment conducted by Georgia Perimeter College. CERTIFICATION:  I certify that the information given on this application is true and correct. I understand that any false information, willful or negligent misrepre-sentation, or failure to disclose any requested information will constitute sufficient grounds for Georgia Perimeter College to terminate my employment without notice. I further understand that the college will perform a pre-employment inquiry including a criminal history check to determine my suitability for employment, and I authorize the college to secure the information necessary to make a decision. I further understand that the college will adhere to the provisions of the fair credit reporting act and other applicable statutes concerning the securing, documentation, handling and release of information obtained in the pre-employment inquiry. I further understand the college is subject to Georgia Open Records laws.Since your 17th birthday, have any law enforcement authorities ever convicted you for violation of federal, state, or municipal law? [ ] yes [ ] noIf YES, answer as to full reason, where charged and disposition of the case. DO NOT INCLUDE MINOR TRAFFIC VIOLATIONS FOR WHICH A FINE OF $100 OR LESS WAS IMPOSED. The existence of a criminal record does not constitute an automatic bar to employment. _______________________________________________________________________________________________________________________________________  _______________________________________________________________________________________________________________________________________  _______________________________________________________________________________________________________________________________________  _______________________________________________________________________________________________________________________________________  ______________________________________________ Signature Rev 01/06 EDUCATION, SKILLS, AND TRAINING
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