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Laredo Community College West End Washington Street, Laredo , TX 7 8 0 4 0 -4 3 9 5 PHO N E (9 5 6 ) 7 2 1 -5 1 3 8 FA X (9 5 6 ) 7 2 1 -5 3 6 7

Website: www.laredo.e du E-mail: hum anresources@laredo.e du

An Equal Opportunity/ Affirmative Action Employer

Application for Employment

Answer All Applicable Questions — Applicants who do not submit a complete application with required supporting credentials will not be considered for position.

PERSONAL DA TA

Date of A pplication Date available for employment

A pplying for: Faculty A djunct Administrative/ Professional/ Technical Classified

Full-Time Part-Time Position for which you are applying:

Name

Last First Middle Social Security N umber

Current Address St reet or P.O. Box City State Zip Code

E-mail Address:

Home Phone: ( ) Work Phone: ( ) Cell Phone: ( )

A re you a United States Citizen? Yes No

If not United States Citizen, what is your Immigration Status? V isa N umber

3. Do you have any relatives employed by Laredo Community College? Yes No If yes, give name( s) and relationship:

The Immigration Reform and Control Act of 1986 require all new employees to provide proof of identity and eligibility to work in the United States.

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XXX-XX-

REQUIRED INFORMATION

4 . Have you ever been convicted of or plead guilty or no contest ( nolo contender) to a misdemeanor, felony or offense involving moral turpitude ( Including, but not limited to, theft, rape, murder, swindling, indecency with a minor , etc.) ?

Yes No If yes, state when, where, and the nature of the offense; indicate whether the charges were dismissed as a condition of probation, suspension, or deferred adjudication. A felony conviction is not an automatic bar to employment. Laredo Community College will consider the nature, date, and relationship between the offense and the position for which you are applying.

1. Employment application packet for Faculty or Administrative/ Professional/ Technical position, must submit application along with: * Resume * Three letters of recommendation ( Letters no more than a year old and hand signed) * Transcript(s) - (Unofficial, however if recommended for position, official transcripts are required ) . If a license or certificate is required for the position for which you are applying, attach a copy of your current license or certificate. 2. Employment application packet for a Classified position, must submit application along with: * Transcript(s) (If applicable) - (Unofficial, however if recommended for position, official transcripts are required) . * High school diploma/GED Certificate If a license or certificate is required for the position for which you are applying, attach a copy of your current license or certificate.

Revised 09-01-15

5. Are you presently employed by Laredo Community College? Yes No 6. Have you ever been employed by Laredo Community College? Yes No If yes, List under Employment Record.

7. Are you willing to do the following: Work on holidays, weekends and/ or evenings Yes No Work at more than one location Yes No Work flexible Schedule Yes No

8. Have you ever been terminated for cause, asked to resign, or left employment involuntarily? Yes No

9. Do you have the required education in the related area as stated in the job description? Yes No List the Diploma/Degree(s) related to the position you are applying for ______________________________________________

1 0 . Do you have the required workexperience in the related area as stated in the job description? Yes No 1 1 . Please describe, your skills and the number of years of experience as they relate to this position.

1 2 . Laredo Community College requires a background check for all positions which means a Criminal Background Check and references are required. Are you willing to have such checks conducted in order to be considered for employment?

Yes No

EDUCATIONAL BACKGROUND

HIGH SCHOOL GED FOREIGN EQUIVALENT DIPLOMA / CERTIFICATE AWARDED? YES NO

COLLEGE UNIVERSITY/TECHNICAL VOCATIONAL SCHOOL ATTENDED

DEGREE ORCOURSE OF STUDY

HOURS COMPLETED

MAJOR MINOR DEGREE AWARDED

YES NO

YES NO

YES NO

YES NO

REFERENCES List three related references that Laredo Community College may contact. (You may not use relatives.)

Name Email or Mailing Address Relationship Telephone Number

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List two references that Laredo Community College may contact. (You may not use relatives.) Name Email or Mailing Address Relationship Telephone Number

w

REQUIRED INFORMATION

If yes, explain

Begin with most recent Education History:

Note: Any coursework or degrees listed must be confirmed with an offical transcript if recommended.

List any special skills you possess in addition to education/training: Languages: Equipment:

Software: License/Certification held: Other:

SPECIAL SKILLS/CERTIFICATIONS/LICENSES

work

personal

Revised 09-01-15

EMPLO YMEN T RECO RD List work experience beginning with the most recent employment: Must be completed

Name of Firm or Organization From Month Year

To Month Year

Address Full-Time Part-Time Position Title:

City and State Phone N umber SUMMARY OF JOB DUTIES & RESPONSIBILITIES: REQUIRED

Name and Title o f Supervisor

Reason fo r Leaving

Name of Firm or Organization Fro m Month Year

To Month Year

Address Full-Time Part-Time Position Title:

City and State Phone N umber

Name and Title of Supervisor

Reason for Leaving

Name of Firm or Organization Fro m Month Year

To Month Year

Address Full-Time Part-Time Position Title:

City and State Phone N umber

Name and Title o f Supervisor

Reason for Leaving

Name of Firm or Organization Fro m Month Year

To Month Year

Address Full-Time Part-Time Position Title:

City and State Phone N umber

Name and Title of Supervisor

Reason for Leaving

Highlights of past work accomplishments ( include publications, awards, etc.) :

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List three personal references that Laredo Community College may contact. (You may not use relatives.)

List three work references that Laredo Community College may contact. (You may not use relatives.)

SUMMARY OF JOB DUTIES & RESPONSIBILITIES: REQUIRED

SUMMARY OF JOB DUTIES & RESPONSIBILITIES: REQUIRED

SUMMARY OF JOB DUTIES & RESPONSIBILITIES: REQUIRED

May we contact this employer? Yes No

May we contact this employer? Yes No

May we contact this employer? Yes No

May we contact this employer? Yes No

If part -time , number of hours per wee k

If part -time, number of hours per wee k

If part -time , number of hours per wee k

If part -time, number of hours per wee k

Revised 09-01-15

Name of Firm or Organization Fro m Month Year

To Month Year

Address Full-Time Part-Time Position Title:

City and State Phone N umber

Name and Title o f Supervisor

Reason fo r Leaving

Name of Firm or Organization Fro m Month Year

To Month Year

Address Full-Time Part-Time Position Title:

City and State Phone N umber

Name and Title o f Supervisor

Reason for Leaving

Name of Firm or Organization Fro m Month Year

To Month Year

Address Full-Time Part-Time Position Title:

City and State Phone N umber

Name and Title o f Supervisor

Reason for Leaving

Name of Firm or Organization Fro m Month Year

To Month Year

Address Full-Time Part-Time Position Title:

City and State Phone N umber

Name and Title o f Supervisor

Reason fo r Leaving

Highlights of past work accomplishments ( include publications, awards, etc.) :

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SUMMARY OF JOB DUTIES & RESPONSIBILITIES: REQUIRED

SUMMARY OF JOB DUTIES & RESPONSIBILITIES: REQUIRED

SUMMARY OF JOB DUTIES & RESPONSIBILITIES: REQUIRED

SUMMARY OF JOB DUTIES & RESPONSIBILITIES: REQUIRED

May we contact this employer? Yes No

May we contact this employer? Yes No

May we contact this employer? Yes No

May we contact this employer? Yes No

EMPLO YMEN T RECO RD List work experience beginning with the most recent employment: Must be completed

If part -time , number of hours per wee k

If part -time , number of hours per wee k

If part -time , number of hours per wee k

If part -time, number of hours per wee k

Revised 09-01-15

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I hereby declare, to the best of my knowledge, that I am not related within the third degree of consanguinity or second degree of affinity according to law, to any member of the Laredo Community College Board of Trustees. I understand that, if employed and a relationship is discovered within a degree prohibited under statute, I will be required to resign my employment at Laredo Community College.

An individual’s relatives within the third degree of consanguinity (blood) are the individual’s: χ Parent or child (first degree); χ Brother, sister, grandparent or grandchild (second degree); and χ Great-grandparent, great-grandchild, aunt or uncle (who is a sibling of a parent of the individual), nephew or niece (who is a child of a brother or sister of the individual) (third degree).

An individual’s relatives within the second degree of affinity (marriage) are the individual’s:

χ Spouse, spouse’s child, spouse’s parent (first degree); and χ Brother’s spouse. Sister’s spouse, spouse’s grandparents, spouse’s grandchild, spouse’s brother or sister (second degree).

The current members of the Board of Trustees are: Dr. Leonides G. Cigarroa, Jr.

Michelle De La Peña Rene De

Dr. Gilberto Martinez, Jr.

Allen Tijerina

I acknowledge that the information provided in this Application for Employment is true and complete to the

best of my knowledge. I understand that any false statement, omission, or misrepresentation may result in the rejection of my application for any position with Laredo Community College, or termination from employment if already employed.

I hereby authorize the Laredo Community College and its duly authorized representatives to obtain information concerning or relating to my past employment. This employment information, both oral and written, may include material contained in my personnel file and evaluative statements and judgments from my former supervisors. This employment information includes, but is not limited to, academic, salary, achievement, performance, attendance, personal history, disciplinary records, and any other employment related information.

I hereby release any individual providing reference or employment information under this authorization, including records custodians, from any and all liability for damages of whatever kind or nature that may at any time result to me on account of compliance, or any attempts to comply with this authorization.

Applicant Signature Date

Laredo Community College is an Equal Opportunity/ Affirmative Action/Veterans Disability Employer.

Applications are subject to a criminal background investigation, and employment is contingent on the result.

I acknowledge that application becomes the property of Laredo Community College. Laredo Community College reserves the right to accept or reject it. This application shall be considered active for a period of 90 days. Any applicant wishing to be considered for employment beyond this time period must submit a new application.

EMPLOYEE STATEMENT CONCERNING NEPOTISM

ACKNOWLEDGEMENT & STATEMENT

La Viña

Mercurio Martinez, Jr.

Cynthia Mares

Jackie Leven Ramos

Ernestina "Tita" C. Vela

Revised 09-01-15

Document Disclaimer: These documents should NOT be construed as legal advice, guidance or counsel. Employers should consult their own attorney about their compliance responsibilities under the FCRA and applicable state law. TruDili gence expressly disclaims any warranties or responsibility or da mages associated with or arising out of information pro vided. Employers seeki ng credit reports mu st provide additional notices pursuant to state law. Revised 09-01-15

APPLICANT Complete the following information as accurately as possible. (Please Print Clearly.) Last: First: Middle:________________ SSN*: D.L./ID# State: ________________ Birth date*: ____________________________________________ Phone: _______________ Professional License Type: State: Lic #: Expiration Date: ____________ Other/Previous names: Date Changed: _______________________ (Attach additional sheet, if necessary.) Date Changed: _______________________ Addresses: (List past seven years beginning with your current address. Include street, city, state, zip code, county and dates

of residence. Attach additional sheet, if necessary.) 1. ________________________City: _______________State: _____ Zip: ________County: __________Dates: ___________ 2. ________________________City: _______________State: _____ Zip: ________County: __________Dates: ___________ 3. ________________________City: _______________State: _____ Zip: ________County: __________Dates: ___________

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK I acknowledge receipt of the FCRA required documents DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT which are both available at http://www.trudiligence.com/downloadforms.php and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, workers compensation bureau or insurance company to furnish any and all background information requested by TruDiligence, LLC, 3190 S Wadsworth Blvd, Suite 260, Lakewood, CO 80227, 800-580-0474, or another outside organization acting on behalf of Employer, and/or Employer itself. I understand that these files may contain negative information about my background, mode of living, character and personal reputation; therefore I agree to defend and hold harmless TruDiligence and any agent acting on its behalf, from any and all liability arising through the investigation of my background. If applicable, I hereby authorize the release of my confidential report to any Third Party directly involved in the hiring or placement process and understand that any release to a third party will not occur until that party has completed a certification regarding the use and viewing of confidential information. I agree to release, hold harmless, and indemnify TruDiligence from any liability, claims, demands, causes of action, damages, or expenses resulting from: any release of information to the Third Party pursuant to this authorization; the unauthorized use of this information by the Third Party; and, any actions taken by the Third Party pursuant to this authorization. I understand that my date of birth is used solely as an identifier to avoid possible misidentification while completing the background check process. I agree that a facsimile (“fax”), electronic, or photographic copy of this Authorization shall be as valid as the original. Signature: Date:

*This information (Birth date and SSN) will be used for background screening purposes only and will not be taken into consideration in making any employment decisions.

BACKGROUND CHECK AUTHORIZATION

TruDiligence Office: (303) 692-8445 Fax: (303) 692-8511 Website: www.trudiligence.com

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