Adjunct Employment Application Listen Name & Contact InformationName * Required First Middle Last Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address * Required Home Phone * RequiredCell Phone * RequiredPosition(s) Applied For * Required Salary Desired * Required Date Available to Start Work * RequiredEducationHigh SchoolName of SchoolMailing AddressDid you Graduate?Degree/Field of Study College, Business, or Trade SchoolName of SchoolMailing AddressDid you Graduate?Degree/Field of Study Professional SchoolName of SchoolMailing AddressDid you Graduate?Degree/Field of Study Other EducationName of SchoolMailing AddressDid you Graduate?Degree/Field of Study List Additional Courses TakenCertificates or Licenses HeldHave you ever been convicted of a felony other than parking or traffic violation? * Required Yes No Please explain.Employment History Give accurate, complete full-time and part-time employment record (up to 7 previous jobs). Start with present or most recent employer. DO NOT STATE "SEE RESUME".Name of Most Recent Employer * Required Name of Last Supervisor * Required Start Date * Required Month Day Year End Date Month Day Year Starting Pay * Required Final/Current Pay * Required How often? * Required Weekly Monthly Complete Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredLast Job Title * Required Reason for Leaving (be specific) * Required List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company. * RequiredMay we contact your employer? * Required Yes No Add a second job? * Required Yes No Name of Employer #2 * Required Name of Last Supervisor * Required Start Date * Required Month Day Year End Date * Required Month Day Year Starting Pay * Required Final Pay * Required How often? * Required Weekly Monthly Complete Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredLast Job Title * Required Reason for Leaving (be specific) * Required List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company. * RequiredMay we contact your employer? * Required Yes No Add a third job? Yes No Name of Employer #3 * Required Name of Last Supervisor * Required Start Date * Required Month Day Year End Date * Required Month Day Year Starting Pay * Required Final Pay * Required How often? * Required Weekly Monthly Complete Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredLast Job Title * Required Reason for Leaving (be specific) * Required List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company. * RequiredMay we contact your employer? * Required Yes No Add a fourth job? Yes No Name of Employer #4 * Required Name of Last Supervisor * Required Start Date * Required Month Day Year End Date * Required Month Day Year Starting Pay * Required Final Pay * Required How often? * Required Weekly Monthly Complete Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredLast Job Title * Required Reason for Leaving (be specific) * Required List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company. * RequiredMay we contact your employer? * Required Yes No Add a fifth job? Yes No Name of Employer #5 * Required Name of Last Supervisor * Required Start Date * Required Month Day Year End Date * Required Month Day Year Starting Pay * Required Final Pay * Required How often? * Required Weekly Monthly Complete Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredLast Job Title * Required Reason for Leaving (be specific) * Required List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company. * RequiredMay we contact your employer? * Required Yes No Add a sixth job? Yes No Name of Employer #6 * Required Name of Last Supervisor * Required Start Date * Required Month Day Year End Date * Required Month Day Year Starting Pay * Required Final Pay * Required How often? * Required Weekly Monthly Complete Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredLast Job Title * Required Reason for Leaving (be specific) * Required List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company. * RequiredMay we contact your employer? * Required Yes No Add a seventh job? Yes No Name of Employer #7 * Required Name of Last Supervisor * Required Start Date * Required Month Day Year End Date * Required Month Day Year Starting Pay * Required Final Pay * Required How often? * Required Weekly Monthly Complete Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number * RequiredLast Job Title * Required Reason for Leaving (be specific) * Required List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company. * RequiredMay we contact your employer? * Required Yes No Skills and/or experiences that you feel would be relevant to position applying for * RequiredReferences Please list 3 references other than relatives and previous employers.Reference 1 Name * Required First Last Position * Required Company * Required Daytime Phone * RequiredEmail * Required Reference 2 Name * Required First Last Position * Required Company * Required Daytime Phone * RequiredEmail * Required Reference 3 Name * Required First Last Position * Required Company * Required Daytime Phone * RequiredEmail * Required Personal StatementWrite a statement telling us why you feel you qualify for and desire this position. * RequiredAdjunct Faculty InformationUndergraduate InformationMajor Field * Required Completed Hours * Required Academic Term * Required Semester Quarter Minor Field * Required Completed Hours * Required Academic Term * Required Semester Quarter Graduate InformationMajor Field * Required Completed Hours * Required Academic Term * Required Semester Quarter Minor Field * Required Completed Hours * Required Academic Term * Required Semester Quarter Total degree and semester hours completed (please select one as of date of this application) * Required Associate Degree Bachelors Degree Masters Degree Educational Specialist Degree Doctorate Degree Others (please specify) Number of Additional Semester Hours * Required Please specify. * Required Teaching AvailabilityPlease indicate which terms(s) you would be available for teaching assignments(s) * Required Fall Spring Summer Please indicate which evening(s) you prefer to be assigned * Required Monday Tuesday Wednesday Thursday Friday Are you available to teaching during the day? * Required Yes No Please indicate when available. * RequiredDay of the WeekStart TimeEnd Time Online? * Required Yes No Military Complete this section if you served in the U.S. Armed Forces.Describe your duties and any specific training.Branch of Service Period of Active Duty (MO & YR) Rank at Discharge Date of Final Discharge Nondiscrimination in Education It is the policy of Northwest Iowa Community College not to discriminate on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, and actual or potential parental, family or marital status in its programs, activities, or employment practices as required by federal and state civil rights statutes and all other applicable federal and state laws, regulations and orders. The Board of Trustees shall monitor progress on this policy through the President's appointed Affirmative Action/Equity Coordinator(s). If you have any questions or complaints related to compliance with this policy, please contact one of the Equity Coordinators at Northwest Iowa Community College, 603 West Park Street, Sheldon, Iowa, room D403b or room A101D, email equity@nwicc.edu, phone number 712-324-5061, extension 113 or extension 137, fax 712-324-4136; or the Director of the Office for Civil Rights, U.S. Department of Education, John C. Kluczynski Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560, Fax: (312) 730-1576, TDD: (800) 877-8339, Email: OCR.Chicago@ed.gov.Application StatementI certify that the information provided by me in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or omission may be grounds for rejection of my application for current and future employment or for termination if I have been employed. I acknowledge that it is the responsibility of the College to hire qualified applicants, and that it is the responsibility of the College to make inquiries as the College, in its discretion, deems relevant to assess work performance. I authorize the College, or its agents, to contact references, to investigate my background, and to make such other inquiries as the College deems relevant to assess my qualifications for the position for which I am applying except where my written statement specifically requests that no reference be made. I release all parties from any liability for such disclosure and I understand that the information disclosed will not be released to me. Finally, I understand that nothing in this application is intended to create an employment contract and that a job offer is not final until all hiring conditions have been met and all required approvals have been obtained. Applicant Statement - Please Read Carefully & Sign Below. * Required Check here to indicate you have read and understood the above statement, and agree. Signature of Applicant * RequiredDate Signed * Required MM slash DD slash YYYY Northwest Iowa Community College Sheldon, Iowa, Employment Policy Statement Northwest Iowa Community College embraces the concept of nondiscrimination in all areas of human and personnel relations. Equal opportunity in recruitment, in employment, and in advancement is guaranteed students, potential students, applicants for employment, and all college personnel regardless ofsex, sexual orientation, gender identity, color, race, national origin, age, religion, disability, or political affiliate or belief. Equal Employment Opportunity Survey The following information is necessary for Northwest Iowa Community College to evaluate its hiring practices and to prepare reports requested by law for the state and federal government. The information will be confidential and will not be used to make a decision about your employment. Your cooperation by providing the information on a voluntary basis will be appreciated. Position(s) Applied For Birth Date Month Day Year Gender Male Female Ethnicity: Are you Hispanic? Yes No Race (choose one or more) American/Alaska native Black or African American White Asian Hawaiian/Pacific Islander Disability Non Disabled Ambulatory/Mobility Visual Hearing Mental/Psychological Other Military Status (Please check all that apply) Veteran Disabled Veteran Spouse of Deceased Veteran Non-Veteran Reservist Where did you hear about this position opening? Newspaper Workforce Development Center Trade Magazine/Newsletter Radio NCC Website Internet Other File(s) UploadFile(s) Drop files here or Select files Accepted file types: pdf, jpg, gif, png, doc, docx, rtf, Max. file size: 256 MB, Max. files: 5. CAPTCHANameThis field is for validation purposes and should be left unchanged.
