ABRAHAM BALDWIN AGRICULTURAL COLLEGE Office of Human Resources ABAC 33 2802 Moore Hwy., Tifton, GA 31793-2601 HR@abac.edu APPLICATION FOR EMPLOYMENT - STAFF and ADMINISTRATORS You may mail this application to the address above. Name (Last, First, Middle) Date Street Address City, State, ZIP Email address Home phone Position or kind of work for which you are applying: Work phone Qualifications, training and special skills: Relevant professional associations, awards, etc. Relevant credentials, licenses, certifications, etc. Education and Training Name of School City/State Did you graduate? High School/GED Yes No Years Completed Degree Major Other School College College Graduate School Employment Experience Name/Location Address From To Current or Last Employer Title/Duties May we contact employer? Reason for Leaving Supervisor name, title, phone, e-mail Name/Location Address From To Previous Employer Title/Duties May we contact employer? Reason for Leaving Supervisor name, title, phone, e-mail 1 7/04 Employment Experience (continued) Name/Location Address From To Previous Employer Title/Duties May we contact employer? Reason for Leaving Supervisor name, title, phone, e-mail Work References (List three) Name/Title Address E-mail address Phone Name/Title Address E-mail address Phone Name/Title Address E-mail address Phone yes no 1. Have you ever been employed by Abraham Baldwin Agricultural College? If so, when? yes no Name 2. Do you have a relative employed at ABAC? If so, list: Position 3. Next of kin: Relationship: yes no 4. Have you ever been dismissed from employment for cause? If so, please explain: 5. Have you ever been convicted of a criminal offense or are there any pending criminal charges against you? yes no If yes, list offense(s) and disposition(s): yes no 6 If required for position, do you have a valid Georgia Driver's License? Certification: Please Read By completing and submitting this application form, the applicant attests to the following: a) I certify that the entries made on this form and information included in any supporting material provided by me are true and correct, and I acknowledge that any false information,misrepresentation, or failure to disclose any requested information will constitute sufficient grounds for termination or removal from consideration for employment. b) I authorize Abraham Baldwin Agricultural College to perform a reasonable pre-employment inquiry to determine my suitability for the position, and I agree that the College may gather information from any sources it deems relevant, and that I will hold Abraham Baldwin Agricultural College harmless for any decisions it may make based on such information. c) I certify that I am eligible for employment in the United States of America and can furnish proof if employed. d) I agree to submit to a criminal and credit (if job-related) background investigation, and/or screening for illegal substances upon conditional offer of employment. Background checks will be performed on all finalist candidates. I understand that an adverse background report may disqualify me from consideration. If background information is the deciding factor in non-selection, I will be provided a copy of the background report. Date Full Name Abraham Baldwin Agricultural College is an Affirmative Action/Equal Employment Opportunity employer and solicits applications from qualified persons regardless of race, color, creed, sex, age or national origin. 2 7/04 ABRAHAM BALDWIN AGRICULTURAL COLLEGE Office of Human Resources, ABAC 33, 2802 Moore Hwy., Tifton, GA 31793-2601 HR@abac.edu This form is voluntary and is not a part of the application packet. It should be mailed separately from the application to the ABAC Human Resources Office. Dear Applicant: Abraham Baldwin Agricultural College is an Equal Employment Opportunity/Affirmative Action employer. As a federal contractor, we are required to compile the following information in order to comply with Federal Equal Employment Opportunity and Affirmative Action requirements. The information you provide is strictly on a voluntary basis and failure to supply it will not in any way affect your employment. Thank you for your interest in employment with Abraham Baldwin Agricultural College. Sincerely, Bertha B. Daniel Director of Human Resources Name: Date: Positions for which you are applying: I WISH TO SELF-IDENTIFY as follows: Please indicate the gender and ethnic group with which you identify. (Definitions are provided below.) Male Female African American American Indian Asian/Pacific Islander Caucasian Hispanic Other (Specify) I DO NOT WISH TO SELF-IDENTIFY AFRICAN AMERICAN (Non-Hispanic): Persons having origins in any of the Black racial groups of Africa. AMERICAN INDIAN/ALASKAN NATIVE: Persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition. ASIAN/PACIFIC ISLANDER: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Pacific Islands. These areas include, for example, China, India, Pakistan, Bangladesh, SriLanka, Nepal, Sikkim, Bhutan, Japan, Korea, Philippine Islands and Samoa. CAUCASIAN (Non-Hispanic): Persons having origins in any of the original peoples of Europe, North Africa or the Middle East. HISPANIC: Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. Only persons from Central and South American countries who are of Spanish origin, descent or culture are included. Persons from Brazil, Guyana, Surinam or Italian heritage who have names that are similar to Spanish surnames in spelling or pronunciation, or persons who acquire a Spanish surname through marriage, are not included in this category. Abraham Baldwin Agricultural College is an AA/ADA/EEO Employer 3 7/04
"Disposition of Application Equal Credit Opportunity"