TEACHING ASSOCIATE APPLICATION FOR EMPLOYMENT

California State University, Chico

Office of the Vice Provost for Human Resources

Chico, California 95929-0024

Voice 530-898-5029 TDD 530-898-5870

Position Title

Department

To comply with the Immigration Reform and Control Act of 1986, all new employees must provide proof of identity and authorization to work.

Name: Last, First, M.I. -- as it appears on your Social Security Card

Previous name(s) used, if different

Mailing Address:

Post Office Box or Number and Street

City, State, and Zip

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Home Phone Number

Work Phone Number

Message Phone Number

EDUCATION

Highest degree received and date of receipt:

Application must be accompanied by transcripts.

Name of School

Major

Diploma/Degree Earned

Professional Schools or Licenses and Certificates:

Other Educational Information:

WORK AUTHORIZATION

California State University, Chico only employs individuals legally authorized to work in the United States. Should you be offered a position on this

campus would you be able to furnish proof that you are authorized to work? r NO r YES If 'no,' explain:

Have you ever been convicted of a crime as an adult (excluding non-felony traffic violations)? r NO r YES A conviction includes a plea, verdict or finding of guilt, regardless of whether a sentence was imposed by the court. You need not provide information about marijuana possession convictions or a violation of Health and Safety Code Section 11357(b) or (c), Section 11360(c), or Section 11364, 11365, or 11550 that occurred more than two years ago. (NOTE: A conviction will not necessarily disqualify an applicant from employment) If 'yes,' explain:

Have you been arrested for any criminal offense for which you are out on bail or on your own recognizance while a trial is pending. (Note: this information cannot be used as a basis to deny employment, unless you are convicted) r NO r YES If 'yes,' explain:

The position for which you have applied may require the use of a state vehicle for state business. If you are offered and accept a position can you furnish proof of a valid California driver's license? NO r YES r If 'no", explain:

EMPLOYMENT HISTORY

Account for work experience during the last 10 years and describe specific duties that are relevant to the position for which you are applying. To allow for accurate review and consideration, your application should provide a complete and detailed description of your work experience. It is to your benefit to be as thorough as possible because this information will be used to determine if you are qualified for this position. You may attach an additional page if more space is required or refer to a résumé only for the duties description.

FROM (mo/yr):

TO (mo/yr):

JOB TITLE or OCCUPATION: Part time r Full time r

NAME OF YOUR DIRECT SUPERVISOR:

EMPLOYER'S NAME and ADDRESS:

SUPERVISOR'S PHONE NUMBER:

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DESCRIPTION OF DUTIES:

REASON FOR LEAVING:

FROM (mo/yr):

TO (mo/yr):

JOB TITLE or OCCUPATION: Part time r Full time r

NAME OF YOUR DIRECT SUPERVISOR:

EMPLOYER'S NAME and ADDRESS:

SUPERVISOR'S PHONE NUMBER:

(

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DESCRIPTION OF DUTIES:

REASON FOR LEAVING: