Ivy Tech Community College
Employment Application

Personal Data

 Date:
Last Name

 First Name
 Middle Name
 Social Security Number
Permanent Address - City

 State Zip Code
 Home Phone
Mailing Address (if different from above)

 Work Phone
Position for which you are applying

 Full-Time?

 Part-Time?

 Salary Expected

 Date Available
Have you previously been employed by the College?
 Location
 Date
Have you ever been convicted of a crime other than a minor traffic offense?
(A conviction will not necessarily disqualify you from the job for which you are applying. A conviction will be judged on its own merits with respect to time, circumstances, and seriousness.
If yes, please explain:
Do you have the legal right to live and work in the U.S.? Yes No
How were you referred to the College?

 Internal Posting
 External Advertisement

Please Specify:  

Education 

 
 

Print name, address, city, state,
and zip code for each school listed

Years Completed

Degree, Major,
or Type of Course

High School

      
 
 

Technical/Community
College

      
 
 

College or University

      
 
 

Graduate School

      
 
 

Other

      
 

Employment History

  
Name and Address of Employer

 Hire Date

Termination Date

Title

Present or
Last Salary:
Reason for leaving:
 
Phone: Briefly describe your duties:

Supervisor:

  
Name and Address of Employer

 Hire Date

Termination Date

Title

Present or
Last Salary:
Reason for leaving:
Phone: Briefly describe your duties:

Supervisor:

 
Name and Address of Employer

 Hire Date

Termination Date

Title

Present or
Last Salary:
Reason for leaving:
Phone: Briefly describe your duties:

 

Supervisor:

 

Please return to the Human Resources Office.
Please read the following carefully.

I understand that I am certifying that my statements on this application are true and complete. Ivy Tech will rely upon my statements as the full truth. Any FALSIFICATION of information in this application will result in my termination regardless of the date of discovery. Also, any OMISSION of information that would have resulted in a decision not to offer employment to me will result in my termination regardless of the date of discovery.

I understand it is my responsibility to provide documentation of credentials as determined by College Human Resource personnel at my own expense.

I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision.
 

Signature

Date

Rev 8/98