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Disposition of Application Equal Credit Opportunity

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					                                               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

				
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