Application for Employment

Application for Employment

Complete the following form and print from your computer. Mail the completed form to Lenoir-Rhyne University, Office of Human Resources, Box 7164, Hickory, NC 28603.

PERSONAL INFORMATION

Application Date:

Full Name:

Preferred Name:

Number & Street:

City:

State:

Zip Code:

Home Phone:

Business Phone:

E-mail Address

Social Security Number*:

* Disclosure of your Social Security Number as an applicant is voluntary and is requested only for administrative
convenience and record keeping accuracy. However, should you be employed, disclosure is mandatory to comply
with the federal Social Security regulation No. 4, Subpart M, Section 404.1242. As an employee, your Social Security
Number would also be used as a personal identifier for University record keeping.

POSITIONS OF INTEREST
Position(s) for which applying:

AVAILABILITY
Please check the types of work you will accept:

Full-time         Part-time        Temporary

Hours available:       Date Available for Employment:

GENERAL INFORMATION
Are you related by blood or marriage to any person now employed at Lenoir-Rhyne University?    No      Yes

If yes, give name, relation and department:

Have you ever been convicted of a misdemeanor or felony other than a minor traffic violation?   No      Yes
If yes, explain (a yes will not automatically disqualify you from employment consideration).

Do you have a valid Driver's License?    No      Yes

EDUCATION
Please indicate your education as follows...

Name and Location of School

Graduated?
yes no
yes no
yes no
yes no Degree

Major

List fields of work for which you are licensed, registered or certified giving date(s), source(s) of issuance, and number(s).

RECRUITMENT INFORMATION
Have you previously been employed by Lenoir-Rhyne University?    No      Yes

I certify that the information I have submitted to seek employment is true, accurate and complete. I authorize
educational institutions, associations, registration and licensing boards, and others to furnish whatever detail
is available concerning my qualifications. I authorize investigation by police departments and other law
enforcement authorities of all statements made in this application and understand that false information or a
failure to disclose information may be grounds for rejection of my application, disciplinary action or dismissal if
I am employed, and possibly criminal action. I further understand that dismissal upon employment shall be mandatory
if fraudulent disclosures are given to meet minimum position qualifications. I also waive any right I may have to
review material or information received from a previous employer or educational institution under a promise
of confidentiality.

Signature_______________________________________       Date____________________________

EMPLOYMENT HISTORY
Please include information related to your last three work experiences. Please feel free to use separate pages to include summaries of other related work and volunteer experiences. Attachment of resumes is encouraged, but does not replace the completion of this work history.

1.  Present or Last Employer

Employer Address

Job Title

Was Position Full-Time?     No      Yes

Supervisor's Name/Telephone Number

Number Supervised by you

Starting Salary $   per      Ending Salary $   per

Date Employment Began (mo/yr)      Date Employment Ended (mo/yr)

Reason for Leaving

Position Duties (List duties in order of importance)

2.  Present or Last Employer

Employer Address

Job Title

Was Position Full-Time?     No      Yes

Supervisor's Name/Telephone Number

Number Supervised by you

Starting Salary $   per    Ending Salary $   per

Date Employment Began (mo/yr)      Date Employment Ended (mo/yr)

Reason for Leaving

Position Duties (List duties in order of importance)

3.  Present or Last Employer

Employer Address

Job Title

Was Position Full-Time?     No      Yes

Supervisor's Name/Telephone Number

Number Supervised by you

Starting Salary $   per     Ending Salary $   per

Date Employment Began (mo/yr)      Date Employment Ended (mo/yr)

Reason for Leaving

Position Duties (List duties in order of importance)

EQUAL EMPLOYMENT OPPORTUNITY STATEMENT AND INFORMATION
Lenoir-Rhyne University administers all educational and employment activities without discrimination related to race, color, religion, national origin, age, disability, sex, or sexual orientation except where exemption is to meet a bona fide occupational qualification. The information requested in no way affects you as an applicant. This equal employment opportunity information will be retained in Human Resources. Its sole use is to ensure that our recruitment efforts reach all segments of the population.

Date of Birth:      Male    Female

ETHNIC GROUP
White (non-Hispanic)
Black (non-Hispanic)
Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, other Spanish origin regardless of race)
Asian (including Pacific Islander)
American Indian (including Alaskan native)
Other (Please Specify)

DISABILITY
A disability is any impairment which substantially limits one or more life activities.
A disabled person is one who:
** actually has such an impairment,
** has a record of such an impairment.

Information reported on this form is confidential and will be maintained in confidential files.
None/prefer not to report
Blind or severely visually impaired
Deaf or severely hearing impaired
Loss or limited use of arms and/or hands
Non-ambulatory (Must use a wheel-chair)
Other orthopedic impairment (Including amputation, debilitating arthritis, back injury, cerebral palsy, spinal bifida, etc.)
Respiratory Impairment
Nervous System/neurological disorder
Mentally restored
Mental retardation
Learning Disability
Other (Please describe)

Print from your computer. Mail the completed form to Lenoir-Rhyne University, Office of Human Resources, Box 7164, Hickory, NC 28603.

� Lenoir-Rhyne University