Human Resources Employment Application

Application for Employment

Position(s) Applying For:

09-15 - Fire Safety Specialist (Manager 170)	09-48 - Associate Dean for Student Academic Policy (Manager 220)
09-49 - Associate Dean for Faculty Development and External Affairs (Manager 220)	09-52 - Part-time Assistant Women's Gymnastic Coach
09-58 - Director of the Women's Center (9-month position) (SUA 3)	09-61 - Associate Dean - College of Visual and Performing Arts
09-71 - Head Men's/Women's Track & Field Coach/Cross Country Assistant	09-72 - Certified Registered Nurse Practitioner (Part-time)
09-76 - Assistant Director of Alumni Relations	09-80 - Dean, Undergraduate Studies and Student Support Services (Manager 220)
09-83 - Business School Program Counselor (SUA 2)

First Name:	Last Name:	Middle Name:
Street Address:
City:	State:	Zip:

Day Telephone:
- -
Cell Phone:
- -
Evening Telephone:
- -
Your Email Address:

Are you a United States Veteran?
Yes No

If yes, forward a copy of the DD-214 or similar official verification of your service to Human Resources.

Are you over eighteen (18) years of age?
Yes No

Citizenship Status:
United States Resident Alien Other

Do you have a current drivers License?
Yes No

Were you ever convicted of a criminal offense or have you ever forfeited a bond or collateral in connection with a criminal charge? (Criminal offences include felonies, misdemeanors, and summary offenses.) A conviction is an adjudication of guilt, concluding determination before a district justice or in criminal court, resulting in a legal penalty such as a fine, sentence, or probation. Omit minor traffic violations.
If “Yes” for conviction, you must list the offense, date of conviction, and deposition. Use separate sheet of paper if necessary.

Yes No

If "Yes" for conviction, you must list the offense, date of conviction, and deposition.
Failure to disclose this information will disqualify your application from the selection process.

Education and Training

High School Last Attended

Name of School:

City:

State:

Graduate:
Yes No

Type of Degree or Diploma and Major Subject:

College University or Technical School

Name of School:

City:

State:

Graduate:
Yes No

Type of Degree or Diploma and Major Subject:

Other

Name of School:

City:

State:

Graduate:
Yes No

Type of Degree or Diploma and Major Subject:

Other

Name of School:

City:

State:

Graduate:
Yes No

Type of Degree or Diploma and Major Subject:

SKILLS:

Typing WPM Word Processing

Shorthand WPM Data Entry

SPECIAL INTERESTS, TALENTS, SKILLS – Please list and/or explain any other skills you feel will be helpful in determining your qualifications for employment at the University:

Employment Record – (Include periods of Military Service)

Present or Most Recent Employer

From:

Month
Year
(format: YYYY)

To:

Month
Year
(format: YYYY)

Employer:
Street Address:
City:
State:
Zip:
Final Position Title:

Specific Duties:

Supervisor's Name:
Phone No:
- -

May we contact this employer?
Yes No

Present or Most Recent Employer

From:

Month
Year
(format: YYYY)

To:

Month
Year
(format: YYYY)

Employer:
Street Address:
City:
State:
Zip:
Final Position Title:

Specific Duties:

Supervisor's Name:
Phone No:
- -

May we contact this employer?
Yes No

Present or Most Recent Employer

From:

Month
Year
(format: YYYY)

To:

Month
Year
(format: YYYY)

Employer:
Street Address:
City:
State:
Zip:
Final Position Title:

Specific Duties:

Supervisor's Name:
Phone No:
- -

May we contact this employer?
Yes No

Supplement Application Information

This information is used ONLY for Social Equity records, will NOT be matched with your application, and is NOT accessible to the hiring manager(s). Completion of this section is NOT mandatory, however, we appreciate and encourage your cooperation.

Racial Designation	Sex	Age Range
White, Non-Hispanic American Indian / Alaska Native Black, Non-Hispanic Latino Asian or Pacific Islander Native American or Native Alaskan Other (Please Specify)	Male Female	Under 18 18 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 69

Disability Status

If yes, check appropriate status: Yes No

Hearing Impaired (including hearing loss & deafness)
Visually Impaired (severe impairment and blindness)
Mobility Impaired
Other
(Please Indicate)

Indicate Source

Posting (internal)
Minority Vita Bank Advertisement
University Employee
Newspaper

Journal
Friend or Relative
Internet
Other

West Chester University is an affirmative action/equal opportunity employer institution committed to extending equality to all individuals regardless of age, race, religion, gender, handicap, national origin, or veteran status. Any individual having suggestions, problems, complaints or grievances with regard to equal opportunity Affirmative Action or Accommodation is encouraged to contact The Director of Social Equity. 1315 University Avenue, West Chester PA 19383. 610-436-2433.
For more information on the University’s crime statistic which is available in a publication called "Your Safety is Our Concern" please contact Public Safety at (610)-436-3311 or by accessing the following website: http://www.wcupa.edu/dps/clery.pdf.

Electronic Resume Attachment

After submitting your application, would you like the option of
attaching an electronic version of your resume and cover letter?
(i.e., Word or PDF)

Yes No

I hereby authorize investigation of all statements contained in this application. I certify that such statements are true, and understand that misrepresentation or omission of facts called for in this form is cause for termination of employment. I also agree: (1) to such examination by a university designated physician as may be required, employment being contingent on the satisfactory passing thereof; (2) If employed, to abide by all regulations of the University.

I have READ and AGREE to the statement above.

West Chester University of Pennsylvania
West Chester, PA 19383
610-436-1000