POSITION APPLICATION

GRAYSON COLLEGE
6101 Grayson Drive
Denison, TX 75020-8299
www.grayson.edu

General Instructions
It is important that you fill out this application completely. Please type or print.

NAME
Last First Middle

ADDRESS
Street City State Zip

TELEPHONE LAST 4 DIGITS OF SS:

Day
E-MAIL ADDRESS
Evening

POSITIONS: Please list in order of preference the positions for which you are applying.
Full-time
First Part-time

Full-time
Second Part-time

I. PERSONAL DATA

CURRENT EMPLOYMENT:
Full-time
Position Part-time

Institution/Company Annual Salary

HAVE YOU EVER PLED GUILTY, NO CONTEST, OR BEEN CONVICTED OF A CRIME (INCLUDING MILITARY)? Yes
If yes, you may attach a statement giving details and current status. No

IF YOU ARE NOT A U.S. CITIZEN, CAN YOU (IF ACCEPTED FOR EMPLOYMENT) PROVIDE PROOF OF YOUR Yes
LEGAL RIGHT AS A NON-CITIZEN TO REMAIN AND WORK IN THE U.S.? No

II. EDUCATION AND PROFESSIONAL TRAINING

Name and Location of School Graduation Major Semester Minor Semester GPA
(List high school first, then college) Degree Area(s) Hours Area(s) Hours Overall

Graduate hours earned above last degree Major area

List any professional certificates or licenses which you hold

AN APPROPRIATE TRANSCRIPT OF ALL COLLEGE CREDITS MUST BE SUBMITTED BEFORE THIS APPLICATION CAN BE CONSIDERED
 III. PROFESSIONAL EDUCATIONAL EXPERIENCE
Months and Name and Location of Name of Supervisor and Subject(s) Taught or Total Total
Years School Phone Number Administrative Duties Months Months
From To Part-Time Full-Time

Summary of Teaching/Administrative Experience (Full-Time Equivalent Years)

Administrative Teaching Administrative Teaching

College or University Public School
Community College Other (Specify)

IV. OTHER EMPLOYMENT EXPERIENCE

(List most recent first)

Years Name and Address of Employer Type of Business Describe Your Duties Reason for
From To Leaving

Total full-time equivalent years of Other Experience (as listed above):

V. PROFESSIONAL ORGANIZATIONS and OTHER ACTIVITIES

(Omit this section if included on resume)

List current professional memberships

List professional committee memberships

List publications

List community activities

Areas of personal interest you might want to mention (hobbies, personal interests, etc.)
 TO BE COMPLETED BY INSTRUCTIONAL APPLICANTS ONLY

VI. RELATED EDUCATIONAL INFORMATION

What experience have you had in co-curricular activities such as student publications, club sponsor, etc.?

Will you be willing to serve as an academic advisor? Yes No

Will you be willing to sponsor student activities? Yes No

What is your view of student activities and services as they relate to the academic program?

Educational experiences: Please check: I Have or Would Like to Have in the following:

Have Would Like Have Would Like

Program Marketing Web Site Development

Internet Based Instruction Educational Television
Program Evaluation Curriculum Revision
Lecture Traditional Microsoft Office or Other
Lecture Team Approach Distance Learning
Interdisciplinary Studies Student Advisement

Alternate Learning Methods, Explain:

Educational Philosophy: Please state your views of the community college.

 VII. ADDITIONAL INFORMATION AND/OR REFERENCES

VIII. ACKNOWLEDGEMENT

I hereby authorize any former employer or any other person given as reference, to answer any and all questions that
may be asked concerning me.

The facts set forth in my application for employment are true and correct. I understand that factual misinformation
on this application shall be considered sufficient cause for dismissal. This application or other application documents
do not create an employee contract or intent to hire.

Signature Date

GRAYSON COLLEGE IS AN EQUAL OPPORTUNITY INSTITUTION PROVIDING EDUCATIONAL AND

EMPLOYMENT OPPORTUNITIES ON THE BASIS OF MERIT AND WITHOUT DISCRIMINATION BECAUSE OF RACE,
CREED, COLOR, RELIGION, GENDER, AGE, NATIONAL ORIGIN, OR DISABILITY.

ADA/Section 504 and Title IX Coordinator:

Vice President for Student Services, 6101 Grayson Drive, Denison, TX 75020 (903) 463-8714
Grayson College Background Investigation Authorization
6101 Grayson Drive Revised: June 2009
Denison, Texas 75020
To Whom It May Concern:
This is to advise that I have made application for employment with Grayson County College for a Security Sensitive Position.

PART I : DEFINITION OF SECURITY SENSITIVE POSITION (Insert a in Appropriate Box from Left to Right)
Handles currency Has access to a computer terminal

Has access to a master key Works in a location designated as a security-sensitive area

PART II: TYPE OF POSITION ( Insert a in Appropriate Box from Left to Right)
Faculty/Adjunct Campus Police Child Care Faculty Dual Credit
Resident Hall Assistant Staff/Maintenance Work Study Other
Position Title:

I, the undersigned, do hereby authorize official(s) of the Grayson College Police Service to conduct such an investigation and do
authorize the release of any and all information requested by this agency pertaining to previous employment, medical record(s),
financial/credit history, character, honesty, and criminal history/records and any other information to determine my suitability and stability
as an employee of Grayson College. If my fingerprints are submitted, I request the results to be returned to the Grayson
College Police Service.

I certify that any person(s) who may furnish such information as listed above may furnish the information concerning me and shall not be
held accountable or liable in any manner. I further agree to waive any right whatsoever to the background investigation reports developed
through this waiver.

PART III: APPLICANT INFORMATION (Please Type or Print Legibly)

Last Name: First Name: Middle Name:

Alias/Maiden Name(s)

SSN: Drivers License Nbr: Drivers License State:

Date of Birth: (MM/DD/YYYY) Race: (Optional) Sex:

Please List any prior STATES(s) of residence for the past ten years. (NOTE: ONLY LIST THE STATE(s) OF
RESIDENCE AFTER AGE 17)

Date: Signature of Applicant:

GIVEN UNDER MY HAND AND SEAL OF OFFICE THE DAY OF , 20 .

S COUNTY OF: STATE OF:

E
A
L (NOTARY PUBLIC SIGNATURE)

Agencies Checked: GCSO TXDPS PDC GC INITIALS: ______________

Campus Police Phone #: (903) 463-8619 E-Mail: safety@grayson.edu
 GRAYSON COLLEGE
EQUAL EMPLOYMENT OPPORTUNITY/AFFIRMATIVE ACTION REQUEST

As a government contractor with an Affirmative Action Program, Grayson College is subject to Executive
Order 11246, as amended; Section 503 of the Rehabilitation Act of 1973; and 38 USC 2012, the Vietnam Era
Veterans Readjustment Act of 1974; the Civil Rights Act of 1991; and the Americans with Disabilities Act. Your
response to the information requested below is voluntary and refusal to provide information will not subject you to
any adverse treatment. This information will be greatly appreciated and will be kept confidential.

PLEASE BE ADVISED THAT THIS SURVEY IS NOT PART OF YOUR OFFICIAL APPLICATION FOR EMPLOYMENT.

RACIAL/ETHNIC GROUP Nonresident Alien Native Hawaiian or Other Pacific Islander

Hispanic/Latino White
American Indian or Alaska Native Two or More Races
Asian Race and Ethnicity Unknown
Black or African American

SEX Male Female DATE OF BIRTH

Qualified Handicapped Individual (defined as any person who has a physical or mental impairment which
substantially limits one or more of such persons major life activities, has record of such impairment or is
regarded as having such impairment). If applicable, please indicate nature of disability:

Qualified Disabled Veteran (defined as anyone entitled to disability compensation under laws
administered by the Veterans Administration for disability rated at 30 percent centum or more, or a
person whose discharge or release from active duty for a disability incurred or aggravated in the line of
duty).

Veteran of the Vietnam Era (defined as one who:

1) a. served on active duty for a period of more than 180 days, any part of which occurred between
August 5, 1965, and May 7, 1975, and was discharged or released therefrom with other than a
dishonorable discharge or
b. was discharged or released from active duty for a service-connected disability if any part of such
active duty was performed between August , 1964, and May 7, 1975; and
2) was discharged or released 48 months preceding the alleged violation of the act, the affirmative
action clause and/or the regulations pursuant to the Act.)

NAME: SOCIAL SECURITY NO:

POSITION SEEKING:
(According to Announcement of Vacancy)

Please return completed form to:

Human Resources
Grayson College
6101 Grayson Drive
Denison, TX 75020-8299

Inquiries concerning the application of Title IX may be referred to the Vice President for Student Services, Title IX Coordinator, Administrative
Services Building, 6101 Grayson Drive, Denison, TX 75020. (903) 463-8714