An Associate Degree Granting College of the University System of Georgia/AA/EOE

Staff Employment Application

Human Resources Department
3251 Panthersville Road
Decatur, GA 30034

PLEASE PRINT LEGIBLY OR TYPE

This form must be completed in its entirety, without including references to an attached resume, and signed.
Department ______________________________________________________

Full-time_____

Part-time _____

Date _____ / _____ / _____

Name ______________________________________________________________________________ SS# _______________________________

Last
First
Middle
Home Address ___________________________________________________________________________________________________________
Street Address
City
State
Zip
Home Phone (

) _____________________Business Phone (

) ______________________Cell Phone (

) _____________________

Mailing Address (if different from above) _______________________________________________________________________________________

Street Address/P.O. Box
City
State
Zip
EMPLOYMENT HISTORY (Please begin with current or most recent employment)
Employer _________________________________

Kind of Business ____________________________

Your Position ____________________________________

Employers Phone Number _____________________

Specic Duties_____________________________________________________________________

Address ____________________________________________________________________________________________________________________________
Employed From _________________ to ______________________
Starting Salary __________________

Total Years _______________

Months________________

Ending Salary _____________

Supervisors Name and Title ____________________________________________________________________________________________________________

Reasons for Leaving ___________________________________________________________________________________________________________________

Employer _________________________________

Kind of Business ____________________________

Your Position ____________________________________

Employers Phone Number _____________________

Specic Duties______________________________________________________________________

Address ____________________________________________________________________________________________________________________________
Employed From _________________ to ______________________
Starting Salary __________________

Total Years _______________

Months________________

Ending Salary _____________

Supervisors Name and Title ____________________________________________________________________________________________________________

Reasons for Leaving __________________________________________________________________________________________________________________

Employer _________________________________

Kind of Business ____________________________

Your Position ____________________________________

Employers Phone Number _____________________

Specic Duties______________________________________________________________________

Address ____________________________________________________________________________________________________________________________
Employed From _________________ to ______________________
Starting Salary __________________

Total Years _______________

Months________________

Ending Salary _____________

Supervisors Name and Title ____________________________________________________________________________________________________________

Reasons for Leaving __________________________________________________________________________________________________________________

MILITARY EXPERIENCE (Complete this section if you served in active duty in the U. S. Armed Forces)
Period of Active Duty ________________________________________________

Grade/Rank at Discharge ______________________________

Branch of Service ________________________________________________Special/Technical Training ____________________________________

[ ] If you are a person with a disability and require any auxiliary aids or services, please check here and a representative will contact you regarding your requirements.
Georgia Perimeter Colleges annual security report includes statistics for the previous three years concerning reported crimes that occurred on campus; in certain off-campus
buildings owned or controlled by Georgia Perimeter College; and on public property within, or immediately adjacent to and accessible from the campus. The report also includes
institutional policies concerning campus security, such as policies concerning alcohol and drug abuse, crime prevention, the reporting of crimes, sexual assault, and other matters.
You may obtain a copy of the report by contacting the Department of Human Resources or by accessing the following website: http//www.gpc.edu/gpcpd/.
Job no. 06-09-061

EDUCATION, SKILLS, AND TRAINING

Education

Name & Address

of School

Dates of Attendance

Year of Graduation

Degree

Highest Grade
Completed

High School

8 9 10 11 12

College

Fr So Jr Sr

Other

Major Subjects ___________________________________________________________________________________________________________

Other Special Training/Skills _________________________________________________________________________________________________
Do you type? _______________ WPM ___________________________

Computer Skills __________________________________________

List any machines you operate _______________________________________________________________________________________________

Professional or Occupational Licenses
Type ______________________________

Number ________________________ Expiration Date __________________________________

Type ______________________________

Number ________________________ Expiration Date __________________________________

Type ______________________________

Number ________________________ Expiration Date __________________________________

Other Qualifications List any pertinent qualifications not previously covered such as published work, community and civic activity, special skills, etc.
(Exclude those that may disclose your gender, sexual orientation, race, color, religion, national origin, age or disabling condition.) ________________
________________________________________________________________________________________________________________________
GENERAL INFORMATION
Are you over the age of 18? [ ] yes

[ ] no

Are you eligible for employment in the United States?

If hired, can you furnish proof of age? [ ] yes

[ ] yes

[ ] no

[ ] no

Have you ever been employed by Georgia Perimeter (DeKalb) College? [ ] yes [ ] no If the answer is yes, give dates, department and job title:
________________________________________________________________________________________________________________________
List name and relationship of any relative employed by Georgia Perimeter College: _____________________________________________________
Are you currently employed at another University System of Georgia Institution? [ ] yes*

[ ] no

*If yes, give name of the institution ___________________________________ Department _______________________________ Title__________
STATEMENT OF POLICY: Georgia Perimeter College is an affirmative action/equal opportunity employer. No person in the United States shall, on the grounds
of race, color, gender, sexual orientation, religion, national origin, age or disability be excluded from employment or participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program of employment conducted by Georgia Perimeter College.
CERTIFICATION: I certify that the information given on this application is true and correct. I understand that any false information, willful or negligent misrepresentation, or failure to disclose any requested information will constitute sufficient grounds for Georgia Perimeter College to terminate my employment without
notice. I further understand that the college will perform a pre-employment inquiry including a criminal history check to determine my suitability for employment,
and I authorize the college to secure the information necessary to make a decision. I further understand that the college will adhere to the provisions of the fair
credit reporting act and other applicable statutes concerning the securing, documentation, handling and release of information obtained in the pre-employment
inquiry. I further understand the college is subject to Georgia Open Records laws.
Since your 17th birthday, have any law enforcement authorities ever convicted you for violation of federal, state, or municipal law? [ ] yes [ ] no
If YES, answer as to full reason, where charged and disposition of the case.
DO NOT INCLUDE MINOR TRAFFIC VIOLATIONS FOR WHICH A FINE OF $100 OR LESS WAS IMPOSED. The existence of a criminal record does not
constitute an automatic bar to employment.
_______________________________________________________________________________________________________________________________________
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_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
______________________________________________
Signature

Rev 01/06