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Home My WebLink AboutEmployee New Hire Bergen Community College is an Equal Opportunity/NJ First Act Employer HR Form 6. Rev 04082020 jd STAFF Employment Application Please PRINT all information Today’s Date: _______________________ Full Time Part Time (Temporary) Position(s) / Job Code Applying for: 1. _______________________ 2. ________________________ Date available to start: _______________ Salary Expectation: ________________ Personal Information Last Name: ____________________________________ First Name: _____________________________ Middle Initial: _____________________ Home Phone (____) _____________________ Alternate Phone: (____) _____________________ Street Address: ___________________________________________________________________________________________________________ City: _______________________________________________________ State: ______________________ Zip: ____________________ Email Address: ____________________________________________________________________________________________________________ Have you ever worked under a different name? Yes No If yes, please state all other names or nicknames necessary for the College to verify your employment or education: _______________________________________________________________________________________________ Are you authorized to work in the United States in the job for which you are applying? Yes No (All employees are required to complete form I-9 within three (3) business days of hire) Do you currently or at anytime need sponsorship to work in the United States? Yes No Have you ever been employed at Bergen Community College? Yes No If yes, please list position, department, dates and reason for leaving: _____________________________________________________________ Are you currently a Bergen Community College student enrolled in more than 6 credits? Yes No Please list any relatives currently employed at Bergen Community College: _____________________________________________________________ How were you referred to Bergen Community College? (Please check or provide source)  Bergen Record  Star Ledger  NY Times  Chronicle of Higher Ed  Diverse Issues in Higher Ed  Hispanic Outlook  College Website  HigherEdjobs.com  Monster.com  Employment Agency  Friend  Relative  Walk-in   Other (please describe): _______________________   Employee referral (please provide name): ____________________________________ Education Background Name /Location Course of Study Academics Honors/GPA Did you graduate or attain a GED? Degree High/Prep School: ______________ ______________ ______________ Yes No ______________ College/University: ______________ ______________ ______________ Yes No ______________ Graduate School: ______________ ______________ ______________ Yes No ______________ Specialized Training: ______________ ______________ ______________ Yes No ______________ Bergen Community College is an Equal Opportunity/NJ First Act Employer HR Form 6. Rev 04082020 jd Licensure/Certifications Please list all professional/technical licenses or certifications (e.g., HVAC, RN, MD, BLS, CRT, RRT, etc.) you have acquired (copies of license/certification required). Type State Licensure/Certification# Expiration Date Pending ___________________ ___________________ ___________________ ____________________ ___________________ ___________________ ___________________ ___________________ ____________________ ___________________ ___________________ ___________________ ___________________ ____________________ ___________________ ___________________ ___________________ ___________________ ____________________ ___________________ If you are applying for a position requiring a License (clinical, driving, etc.), has such license ever been suspended or revoked or have you ever been otherwise disciplined by the licensing authorities? Yes No If yes, provide details: _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Military Record Service Have you been a member of the Armed Services of the United States? Yes No Rank at Discharge: _____________________ Branch: ___________________ Dates: ___________________________ Employment History Complete this section even if resume is attached; list most recent first. Check if resume has been attached to application. Dates Employed: From: ____________/___________To: __________/___________ Type of Business: ________________________ Month Year Month Year Name of Employer: __________________________________________________ Phone# (_______) _________________________ Address: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Name/Title of Last Supervisor: ________________________________________ May we contact? Yes No Your Job Title: ________________________________ This position is/was: Full Time Part Time Contract Seasonal Description of Duties: _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Reason for leaving: _________________________________________________________________________________________________________ Dates Employed: From: ____________/___________To: __________/___________ Type of Business: ________________________ Month Year Month Year Name of Employer: __________________________________________________ Phone# (_______) _________________________ Address: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Name/Title of Last Supervisor: ________________________________________ May we contact? Yes No Your Job Title: ________________________________ Bergen Community College is an Equal Opportunity/NJ First Act Employer HR Form 6. Rev 04082020 jd This position is/was: Full Time Part Time Contract Seasonal Description of Duties: _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Reason for leaving: _________________________________________________________________________________________________________ Dates Employed: From: ____________/___________To: __________/___________ Type of Business: ________________________ Month Year Month Year Name of Employer: __________________________________________________ Phone# (_______) _________________________ Address: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Name/Title of Last Supervisor: ________________________________________ May we contact? Yes No Your Job Title: ________________________________ This position is/was: Full Time Part Time Contract Seasonal Description of Duties: _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Reason for leaving: _________________________________________________________________________________________________________ Dates Employed: From: ____________/___________To: __________/___________ Type of Business: ________________________ Month Year Month Year Name of Employer: __________________________________________________ Phone# (_______) _________________________ Address: _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Name/Title of Last Supervisor: ________________________________________ May we contact? Yes No Your Job Title: ________________________________ This position is/was: Full Time Part Time Contract Seasonal Description of Duties: _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Reason for leaving: ________________________________________________________________________________________________________ Special Training Typing (WPM): _____________ Foreign Languages: Speak ____________ Read ____________ Write___________ Please list other applicable experiences, skills, training or qualifications (professional, technical and/or mechanical) ________________________________________________________________________________________________________________________ Bergen Community College is an Equal Opportunity/NJ First Act Employer HR Form 6. Rev 04082020 jd With or without reasonable accommodation, do you have the ability to perform the essential functions of the job you are applying for: Yes No Employment Application Consent Release I hereby certify that the facts set forth in the completed employment application are true and complete to the best of my knowledge. I understand that any misrepresentation or false statements in this application will be considered grounds for immediate dismissal. This college does not discriminate in hiring or any other decision on the basis of race, sex, sexual orientation, citizenship, national origin, ancestry, Vietnam era veteran status or on the basis of age, physical/mental disability unrelated to ability to perform the work required. I authorize the investigation of all statements contained herein as a condition of employment. I authorize Bergen Community College and/or its agents, including consumer reporting bureaus, to verify any of this information including, but not limited to, criminal history, motor vehicle driving records, and salary verifications. I release all persons, schools, colleges/universities, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. In addition, as a part of the College’s hiring process and in conjunction with collective bargaining unit agreement, certain positions are considered safety-sensitive and are subject to a drug screening test. After an offer of employment and prior to reporting to my workstation, I understand that if I am hired into a safety-sensitive position, I agree to submit to a drug screening test. I also understand that my potential employment is contingent upon receipt of satisfactory references, background checks, and approval by the Board of Trustees. I understand that this application is not, nor is it intended to be, a contract of employment. I agree to abide by all rules and regulations of Bergen Community College. Applicant’s Signature: ___________________________________________________ Date: _________________________ Applicant Printed Name: ___________________________________________________