Employment Application Applicant Information Full Name : Date: Last First M.I. Address: Street Address Apartment/Unit # City State ZIP Code Phone: ( ) E-mail A ddress: Date Available: Social Security No.: Desired Salary: $ Position Applied for: Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO Are you willing to r elocate ? YES NO If no, why? Have you ever been convicted of a felony? YES NO If yes, explain: Education High School: Address: From: To: Did you graduate? YES NO Degree: College: Address: From: To: Did you graduate? YES NO Degree: Other: Address: From: To: Did you graduate? YES NO Degree: References Please list three professional references. Full Name: Relationship : Company : Phone: ( ) Address: Full Name : Relationship : Company: Phone: ( ) Address: Full Name: Relations hip: Company: Phone: ( ) Address: Coffeyville Community College , 400 W 11th St., Coffeyville, KS 67337 Previous Employment Company: Phone: ( ) Address: Supervisor: Job Title: Starting Salary: $ Ending Salary: $ Responsibilities: From: To: Reason for L eaving: May we contact your previous supervisor for a reference? YES NO Company: Phone: ( ) Address: Supervisor: Job Title: Starting Salary: $ Ending Salary: $ Responsibilities: From: To: Reason for L eaving: May we contact your previous supervisor for a reference? YES NO Company: Phone: ( ) Address: Supervisor: Job Title: Starting Salary: $ Ending Salary: $ Responsibilities: From: To: Reason for L eaving: May we contact your previous superv isor for a reference? YES NO Skills and Qualifications (List those pertaining to position for which you are applying ) Skills : Computer Skills : List any special accomplishmen ts: Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Signature: Date: Consumer Information As an institution who participates in the Federal Student Aid program, consumer information is available on the CCC website at www.coffeyville.edu. Upon request to the financial aid office, a paper copy of any desired document will be made available. Consumer Information includes: • Annual Campus Security Report • Financial Aid Assistance Information • Academic programs and policies • Graduation and completion rates • Summary of the Equity in Athletic Report Coffeyville Community College strives to provide a safe and secure environment for its campus community members. Each year, CCC publishes an Annual Security and Fire Safety Report which discusses topics such as crime prevention, to whom crime reports should be filed, resources for victims of crimes, emergency procedures, and other matters of importance related to security and safety at CCC. The report also contains statistics for specific crimes reported to have occurred on certain property owned or controlled by the College over the past three calendar years. This report is available on the CCC website at: Coffeyville Main Campus: http://www.coffeyville.edu/securityreportmaincampus Coffeyville Technical Campus: http://www.coffeyville.edu/securityreportcoffeyvilletech Columbus Technical Campus: http://www.coffeyville.edu/securityreportcolumbus If you would like to receive a hard copy of the report at no charge, you may do so by making a request to the Chief Financial Officer ( CFO ) at 620 -252-7177, travis.young@coffeyville.edu or the Business Office located on the second floor of the Student Union.
