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THE UNIVERSITY OF TEXAS

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THE UNIVERSITY OF TEXAS Powered By Docstoc
					                                                       The University of Texas
                                                         of the Permian Basin
                                                      Office of Human Resources
                                                    4901 East University Boulevard
                                                      Odessa, Texas 79762-0001
                                                            (432) 552-2747
                                                         Fax: (432) 552-3747

                          APPLICATION FOR EMPLOYMENT


                                    Notice About Social Security Numbers

Disclosure of your SSN is mandatory before you may be employed by the University. Federal law requires the
University to report income and SSNs for all employees to whom compensation is paid. Employee SSNs are
maintained and used by The University of Texas of the Permian Basin for payroll and benefits purposes and are
reported to Federal and State agencies on forms required by law for benefits purposes. Further disclosure of
your social security number will be governed by the Public Information Act (Chapter 552 of the Texas
Government Code).

                                Notice about Information Laws and Practices

With few exceptions, you are entitled on your request to be informed about the information The University of
Texas of the Permian Basin collects about you. Under Sections 552.01 and 552.023 of the Texas Government
Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government
Code, you are entitled to have the University correct information about you that is held by us and is incorrect, in
accordance with the procedures set forth in The University of Texas System Business Procedures Memorandum
32. The information that The University collects will be retained and maintained as required by Texas records
retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of
information are kept for different periods of time.

In compliance with H.B. 558 passed during the 76th legislative session, The University of Texas of the Permian
Basin requires male citizens/nationals who are from 18 to 26 years of age to provide proof of registration with
the Selective Service System of exemption from registration, prior to employment.

                                        An Equal Opportunity Employer
                                                                The University of Texas of the Permian Basin
                                                                Office of Human Resources

                                                                4901 E. University
Application for Employment                                      Odessa, TX 79762
  An Equal Opportunity/Affirmative Action Employer              (432) 552-2747 Fax: (432) 552-3747
                                                                http://www.utpb.edu/vpba/person/jobpage.htm


                                                                        Today's Date
              Please Print Clearly
Last Name                                                               First Name                                           Middle

Street Address                                                          City                                                 State        Zip

Home Phone Number                                                       Work Phone Number                                    Other



Have you ever filed an application at UTPB before?                                   If YES, give date:
 
YES        
           NO
Have you ever been employed at UTPB, other University of Texas                       If YES, indicate where and when:
component, or any other state agency?       
                                           YES        
                                                      NO
Are you related by kinship or marriage to any current UTPB, UT                       If YES, please give name and relationship:
System or Board of Regent member? YES  NO
Have you ever been convicted, or pled guilty or no contest to, a felony              If YES, please explain:
offense?    
           YES         
                       NO       Year of conviction
Driver’s License: (if required for this position)                                    Operator                
State:                          Number:                                              Commercial              
If hired, are you eligible to work in the United States?                             Who referred you to this institution?
 
YES        
           NO


Job Preferred                                         Full Time               Temporary                 Part Time   Date available for employment:
                                                      


 Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED

       Schools                               Name and Location                                                  Miscellaneous Information
High School Graduate
                                                                                                  Voc. Tech.              
                                                                                                                   Business  College Prep 
Yes No                                                                                                Hours               Degree       Major/Minor
Junior/Community
College(s)
College(s) and/or
University(ies)
Graduate and/or
Professional
Voc Tech., Other                                                                                                                          Certificate
                                                                                                                                             
                                                                                                                                        Yes No 
Your application and the interviews that may follow inform us of your knowledge, interest skills and abilities. It will be
to your advantage to provide us with Complete, Accurate, and Honest answers to each question. The filling of your
application and our acceptance do not in any way obligate the University. If you are employed, this data will become a
part of your permanent personnel record. Your interest in employment at The University of Texas of the Permian Basin is
appreciated.
Employment History
Please list all employment starting with present or most recent employer. Account for all periods, including unemployment and service
with U.S. Armed Forces. Also include relevant voluntary and/or part-time work experience. Ask for additional sheets, if necessary.
May we contact your present employer?        Yes  No       

 Employer (Name of firm or agency)                                 Address (Street, City, State)

 Job Title                                                         Supervisor's Name/Title                     Phone Number

 Duties:

 Starting Annual       Ending Annual          Full Time            Part Time          Hours per week           Dates Employed
 Salary:               Salary:                                                                                 From         To
 Specific Reason for Leaving:




 Employer (Name of firm or agency)                                 Address (Street,City,State)

 Job Title                                                         Supervisor's Name/Title                     Phone Number

 Duties:

 Starting Salary        Ending Salary         Full Time            Part Time          Hours per week           Dates Employed
                                                                                                               From         To
 Specific Reason for Leaving:




 Employer (Name of firm or agency)                                 Address (Street,City,State)

 Job Title                                                         Supervisor's Name/Title                     Phone Number

 Duties:

 Starting Salary        Ending Salary         Full Time            Part Time          Hours per week           Dates Employed
                                                                                                               From         To
 Specific Reason for Leaving:




PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND INDICATE YOUR UNDERSTANDING AND ACCEPTANCE BY
SIGNING IN THE SPACE PROVIDED

I certify that the statements made by me in connection with this application, whether on this document or not, are true, complete, and
correct to the best of my knowledge and belief and are made in good faith. I understand that any false statements made herein,
including omissions, will void this application and any actions based on it. I understand that any offer of employment tendered me is
contingent upon my agreement to abide by all rules and regulations of the Board of Regents of The University of Texas System.


______________________________________
____________________________________________________________________
Date                                                               Signature of Applicant
                                      Supplemental Employment History
Employer (Name of firm or agency)                             Address (Street, City, State)

Job Title                                                     Supervisor's Name/Title             Phone Number

Duties:

Starting Salary       Ending Salary        Full Time          Part Time          Hours per week   Dates Employed
                                                                                                  From         To
Reason for leaving:

Explain any break in employment after leaving this position: Dates From_________ To_________



Employer (Name of firm or agency)                             Address (Street,City,State)

Job Title                                                     Supervisor's Name/Title             Phone Number

Duties:

Starting Salary       Ending Salary        Full Time          Part Time          Hours per week   Dates Employed
                                                                                                  From         To
Reason for leaving:

Explain any break in employment after leaving this position: Dates From_________ To_________



Employer (Name of firm or agency)                             Address (Street,City,State)

Job Title                                                     Supervisor's Name/Title             Phone Number

Duties:

Starting Salary       Ending Salary        Full Time          Part Time          Hours per week   Dates Employed
                                                                                                  From         To
Reason for leaving:

Explain any break in employment after leaving this position: Dates From_________ To_________



Employer (Name of firm or agency)                             Address (Street,City,State)

Job Title                                                     Supervisor's Name/Title             Phone Number

Duties:

Starting Salary       Ending Salary        Full Time          Part Time          Hours per week   Dates Employed
                                                                                                  From         To
Reason for leaving:

Explain any break in employment after leaving this position: Dates From_________ To_________

				
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