Application For Staff Employment

APPLICATION FOR EMPLOYMENT

Harvey Mudd College is an equal opportunity employer and does not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should contact the Human Resources Office.

APPLICANT INFORMATION
Last Name: (Required)	First Name: (Required)	Middle Name:
Street Address: (Required)	City: (Required)	State: (Required)	Zip: (Required)
Previous Address (Complete only if at current address less than 2 years):	City:	State:	Zip:
Home Phone #:	Message Phone #:	Preferred Contact #:	Contact Email Address:

POSITION DESIRED (A separate application must be submitted for each position for which you are applying.)
Position Applying For: (Required)	Posting Number: (Required)
Minimum Rate of Pay:	Date Available:
Type of Work Desired: (Required) Full Time Part Time Either

PERSONAL INFORMATION
If hired, can you submit proof of your legal right to live and work in the United States? (Required)	YesNo

Are you at least 18 years of age or older? If “no,” a work permit may be required. (Required)	YesNo

Have you ever worked under or been known by another name? (Required) If "yes," please give name(s) and date(s) used. (This information is used in reference checking.):	YesNo

Have you ever worked for any of The Claremont Colleges and/or the Claremont University Consortium? (Required) If "yes," please list which institution(s)?:	YesNo

Are any of your relatives or friends presently employed by Harvey Mudd College? (Required) If yes, give full name and position:	YesNo

Have you ever been convicted by any court of an offense, and/or have you been arrested for a crime for which trial is now pending? If yes, please explain. (Required)	YesNo
(A plea of guilty or no contest must be reported. You do not need to report the following: (1) minor traffic violations; (2) any arrest or detention that did not result in conviction; (3) any conviction for which the record has been judicially expunged, sealed, or eradicated, such as certain juvenile offense records; ( 4) any misdemeanor conviction for which probation has been completed and the case has been judicially dismissed; (5) any arrest for which a pretrial diversion program has been successfully completed; or (6) convictions for certain marijuana violations that are more than two years old, per California Labor Code section 432.8.) (Note: A conviction is not an automatic bar to employment. The nature of the offense, date of offense, the surrounding circumstances and relevance of the offense to the position applied for will be considered.)

Have you ever been discharged from employment, asked to resign, or advised that if you did not resign, your employment would be terminated? (Required) If yes, please explain:	YesNo

Type of School	No. of Years Completed	Did You Graduate?
EDUCATION AND TRAINING
High School/ GED/CHSPE		Yes No
Business/Trade or Technical School		Yes No
College(s) or University(ies)		Yes No

Are you attending school now? Yes No	Name/Course of Study:

SPECIAL SKILLS
Licenses/Certificates:	Answer only if position applied for requires a driver’s license. Do you have a valid driver’s license issued by the State of California? Yes No
Keyboarding WPM:	Computer Programs:
Special Equipment:
List language(s) (optional) other than English that you:
Speak Read Write Interpret and/or translate
Do you have any other experience, training, qualifications or skills, which you feel, make you especially suited for the position for which you are applying?Yes No If yes, please explain.

EMPLOYMENT HISTORY

For the last 10 years, starting with most recent, list each job held and account for all periods of unemployment. Attach additional sheets if necessary.

EMPLOYER 1:		May we contact this employer: Yes No
Address:		Phone:
Supervisor’s Name:		Phone:
Date Started: Date Left: Starting Salary: Ending Salary:
Title or Position:
Duties and Responsibilities:
Reason for Leaving:
Account for periods of unemployment between jobs:

EMPLOYER 2:		May we contact this employer: Yes No
Address:		Phone:
Supervisor’s Name:		Phone:
Date Started: Date Left: Starting Salary: Ending Salary:
Title or Position:
Duties and Responsibilities:
Reason for Leaving:
Account for periods of unemployment between jobs:

EMPLOYER 3:		May we contact this employer: Yes No
Address:		Phone:
Supervisor’s Name:		Phone:
Date Started: Date Left: Starting Salary: Ending Salary:
Title or Position:
Duties and Responsibilities:
Reason for Leaving:
Account for periods of unemployment between jobs:

EMPLOYER 4:		May we contact this employer: Yes No
Address:		Phone:
Supervisor’s Name:		Phone:
Date Started: Date Left: Starting Salary: Ending Salary:
Title or Position:
Duties and Responsibilities:
Reason for Leaving:
Account for periods of unemployment between jobs:

UPLOAD FILES (optional)

If you would like to include your resume or other files, please upload it as a Microsoft Word (.doc or .docx) file or a PDF (.pdf).

CERTIFICATION (Required)
Important, please read carefully and sign.

I hereby certify that the information on this application and all other information otherwise provided are true and correct. I
understand that any misrepresentations or omissions will be sufficient cause for cancellation of this application or immediate
termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an
agreement or contract for employment. Accordingly, either I or the institution can terminate the relationship at will, with or without
cause, at any time. I further acknowledge that the only manner in which the “at will” nature of the employment relationship can be
altered is by means of a specific written agreement signed by me and the institution’s President or designated Vice President.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

I agree I disagree

APPLICANT IDENTIFICATION RECORD
As an affirmative action/equal opportunity employer, Harvey Mudd College is required to compile summary data on applicants for employment. The College requests your assistance by responding to the following questions. Your decision to respond to the questions is strictly voluntary and will not affect consideration of your application. This form will be kept confidential and separate from all hiring documents and will not be forwarded to the hiring department.



What is your gender?

Male
Female
Other (please specify)

Do you consider yourself to be of either Hispanic or of Latino origin? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
Yes No

Race (please select appropriate box or boxes):
American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America [including Central America], and who maintains tribal affiliation or community attachment.)
Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)
Black or African American (A person having origins in any of the black racial groups of Africa.)
Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa.)

Where did you learn about this position? Harvey Mudd College Website Harvey Mudd College on-campus job posting Referred by someone Employment website (please specify) Newspaper, journal, other publication (please specify) Other (please specify)