San Jose/Evergreen Community College District

Application for Administrative Position

DO NOT COMPLETE ANY SECTION BY REFERENCE TO RESUME
OR OTHER DOCUMENTATION.
THIS WILL RESULT IN AN INCOMPLETE APPLICATION FORM

INSTRUCTIONS:

To print out a copy of this form, type in your answers and then click on the "Compose for Printing" button at the bottom. That will regenerate the form into a page that you can print, complete with your typewritten answers. You may edit your information by going back and reentering and again clicking on the "Compose for Printing" button at the bottom. When you are satisfied with the form print it out on your printer. Once printed, make sure you sign your name on the printed application before faxing or sending it with other required documents to the San Jose/Evergreen Community College District. An alternative method is to print out this form and then fill it in by hand or using a typewriter.

Please note that this is not a form you can submit via email.

IF YOU MAKE ANY CHANGES TO THIS FORM AFTER CLICKING THE "Compose for Printing" BUTTON YOU MUST CLICK "Compose for Printing" AGAIN.

Position Title:
Position #:

Personal Data

Name

Last, First, Middle Initial
Day Phone

(area code) phone number
Current Address

Eve. Phone

(area code) phone number
E-mail Address
Soc. Sec.#

Do you hold a California credential valid at the community college level? Yes
 No
-Name of credential(s)/subject areas
Has your credential ever been suspended or revoked?
-If you answer yes, attach a written explanation. 		Yes
 No
Are you applying for equivalency to meet minimum qualifications?
(see job description) 		Yes
 No
Have you ever been arrested for any crime (other than a minor traffic violation) which resulted in a conviction or a plea of nolo contendere?
-If you answer yes, attach a separate written explanation. 		Yes
 No
Have you ever been dismissed or asked to resign from any teaching or administrative position?
-If you answer yes, attach a written explanation of the situation. 		Yes
 No
Do you have any relatives currently working for the District?
-If you answer yes, please list names and titles: 		Yes
 No

Education

Applicant must submit a complete transcript of all college work. Unofficial transcripts are acceptable for pre-employment purposes. However, an employment offer is contingent upon verification of official transcripts.

*If degree is pending, indicate date degree is expected to be awarded.

1. Name of Institution/Location:

Major:

Minor:

*Degrees Completed:

2. Name of Institution/Location:

Major:

Minor:

*Degrees Completed:

3. Name of Institution/Location:

Major:

Minor:

*Degrees Completed:

4. Name of Institution/Location:

Major:

Minor:

*Degrees Completed:

Administrative Experience

(In chronological order, list most recent first.)

1. Name of Institution/Location:

From Month/Year to Month/Year:

Position:

Part Time/Full Time

Reason For Leaving:

2. Name of Institution/Location:

From Month/Year to Month/Year:

Position:

Part Time/Full Time:

Reason For Leaving:

3. Name of Institution/Location:

From Month/Year to Month/Year:

Position:

Part Time/Full Time:

Reason For Leaving:

4. Name of Institution/Location:

From Month/Year to Month/Year:

Position:

Part Time/Full Time:

Reason For Leaving:

Non-Administrative, Teaching or other Academic/Professional Experience

(In chronological order, list most recent first. Use an additional sheet if necessary.)

1. Name of Institution/Location:

From Month/Year to Month/Year:

Subject:

Part Time/Full Time:

Reason For Leaving:

2. Name of Institution/Location:

From Month/Year to Month/Year:

Subject:

Part Time/Full Time:

Reason For Leaving:

3. Name of Institution/Location:

From Month/Year to Month/Year:

Subject:

Part Time/Full Time:

Reason For Leaving:

4. Name of Institution/Location:

From Month/Year to Month/Year:

Subject:

Part Time/Full Time:

Reason For Leaving:

References

List at least three current professional references, include a recent supervisor and persons who have first hand knowledge of your professional skills and abilities.

1. Person/Institution/Location:

Official Title:

Phone #:

Professional Relationship:

2. Person/Institution/Location:

Official Title:

Phone #:

Professional Relationship:

3. Person/Institution/Location:

Official Title:

Phone #:

Professional Relationship:

4. Person/Institution/Location:

Official Title:

Phone #:

Professional Relationship:

Relevant Qualifications/Training and Licenses

Indicate below any information about yourself that would be helpful in considering your application.

Please attach any additional information that does not fit into this text block.

Original Statement

Must be completed by each applicant. Please limit your comments to the one page.

Please write a brief narrative focusing upon your philosophy and experience concerning:

a. The role and function(s) of the community college.
b. The role and function(s) of an administrator in a community college.
c. Your role in working with the diverse population of a community college.


Applicant Survey
(Voluntary)

This survey will be separated from the employment application immediately upon receipt in the Human Resources Department. The following information is helpful for the San Jose/Evergreen Community College District to evaluate its hiring practices and to prepare reports requested by law for the state and federal government. The information will be confidential and will NOT be used to make a decision about your employment, nor will it be seen by persons involved in the application process.

Name
Date of Application

Position for which you are applying
Sex:    Male   Female

Race/Ethnic Group - Please check the one you feel best represents your Race/Ethnicity: (check one)

American Indian/Alaskan Native
African American
Asian/Pacific Islander
Asian Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Japanese
Korean
Laotian
Samoan
Vietnamese
Other Asian/Pacific Islander
Central American
Hispanic
Mexican/Mexican American/Chicano
South American
White, Non-Hispanic
Other Non-White
     
Other
     
Decline to State

Are you over 40 years of age? Yes

 No
Do you have a disability?
(An individual with a disability is a person who has (1) a physical or mental impairment that substantially limits one or more major life activities; or (2) a record of such an impairment; or (3) is regarded as having such an impairment.) 		Yes

 No
Are you a Vietnam Era Veteran?
(Service dates must be between August 5, 1964 - May 7, 1975) 		Yes

 		No
Where did you hear about this position?
Asian Pacific Careers
Black Careers
Black Issues in Higher Education
Career Builder
Chronicle of Higher Education
Disabledperson.com
District Employee
Flyer (Please specify)
     
Friend or Word of Mouth
HERC (Higher Ed. Recruitment         Consortium)
Higheredjobs.com
Hispanic Hotline
Hotjobs.com
NABSE (National Alliance of Black School         Educators)
Nuevo Mundo
Opportunity Knocks
Registry Job Fair
Registry Online - cccregistry.org
San Jose Mercury News
San Jose/Evergreen District or College         Web Site
SpartaJobs
VietMerc
Other Job Fair (please specify)
     
Other Website (please specify)
     
Other (please specify)
     

Pursuant to Section 504 of the Rehabilitation Act of 1973 as amended and Section I of the Americans with Disabilities Act, disabled persons who believe they need reasonable accommodations or help in order to apply for or perform the necessary duties of a position may contact the Office of Human Resources at San Jose/Evergreen Community College District, Phone 270-6406.


San Jose/Evergreen Community College District is an Equal Employment Opportunity/Affirmative Action, Title IX, Section 504 Employer. Questions concerning the application of this policy may be addressed to the Human Resources Director, San Jose/Evergreen Community College District.


Please be sure to sign your application form once it has been printed.