Date ___________________________
Name ______________________________________________________________________________
Last First Middle
University/
Business Address _____________________________________ Office Phone ____________________
_____________________________________ Fax. # __________________________
E-mail Address _____________________________________
Home Address _______________________________________ Home Phone _____________________
No. & Street
________________________________________________
City, State Zip Code
Can you, after employment, submit verification of your legal right to work in the United States? ______
DEGREES
Bachelor’s ____________________ ____________________ _________________________________
Degree Field Institution
Master’s ______________________ ____________________ _________________________________
Degree Field Institution
Doctorate ______________________ ____________________ ________________________________
Degree Field Institution
Do you have any condition or physical disability which would impair your performance of the functions of the position applied for? _____________________________________________________________
If the answer is yes and you could perform such functions with accommodation, what is the nature of the accommodation required? ______________________________________________________________
___________________________________________________________________________________
Have you ever been convicted as an adult of other than minor traffic violations? ___________________
If yes, please explain (include dates) _____________________________________________________
___________________________________________________________________________________
Are you now or have you ever been employed by CSUSB? [ ] Yes [ ] No
If yes, when __________________________________________________________________
Currently contributing to or receiving retirement benefits from:
PERS __________ STRS __________ Neither __________
The Immigration Reform and Control Act of 1986, Public Law
99-603, requires that employers obtain documentation from every new employee
which confirms identity and authorizes that individual to accept employment in
this country. This requirement applies
to both United States citizens and aliens.
Can you provide the necessary documentation at the start of employment? Yes
[ ] No
[ ]
If you are employed by California State University, San
Bernardino, you will be required to sign the State Employee’s Oath of
Allegiance swearing (or affirming) your support of the Constitution of the
United States and the State of California (non-citizens are exempted). Are you willing to sign such an oath?
Yes [ ]
No [ ]
The
Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics
Act requires the notice of availability of the annual campus security report to
prospective faculty. The annual security report includes statistics for the
previous three years concerning reported crimes that occurred on campus; in
certain off-campus buildings or property owned or controlled by the California
State University and on public property within, or immediately adjacent to and
accessible from, the campus. The report also includes institutional policies
concerning campus security, such as policies concerning alcohol and drug use,
crime prevention, the reporting of crimes, sexual assault, and other matters.
You can obtain a copy of this report by contacting the campus Office of Public
Safety or by accessing the following website:
http://publicsafety.csusb.edu/safetyreport.html
This
information may be used only for the purpose of employment in accordance with
the Information Act of 1977.
I hereby certify that the information contained in this application form is true, complete and correct to the best of my knowledge and agree to have any of the statements checked by the University unless I have indicated to the contrary. I authorize the individuals and/or organizations, entities or agencies described in this application to release to the University any and all information concerning my previous employment (including, but not limited to, achievement, performance, attendance, etc.) an any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the University as well as from the use or disclosure of such information by the University or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, may be considered cause for my termination.
______________________________________________________ ________________________
Applicant’s Signature Date
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