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Application for Employment


Position(s) Applying For:
<< Read Job Descriptions
14-110 - Program Counselor - Psychology Department (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 offenses include felonies and misdemeanors.) 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

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.

RaceSexAge Range

American Indian or Alaska Native
(Persons 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
(Persons having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian Islands,including, for example Cambodia, China, India, Japan,Korea, Malaysia, Pakistan, the Philippines, Thialand and Vietnam.
Black or African American
(Persons having origins in any of the black racial groups of Africa).
Native Hawaiian or Pacific Islander
(Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).
White/Caucasian
(Persons having origins in any of the original peoples of Europe, the Middle East, or North America).
Two or More Races
Male
Female
Under 18
18 - 29
30 - 39
40 - 49
50 - 59
60 - 69
Over 69

Disability StatusEthnicity
If yes, check appropriate status:
Yes  No

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

Hispanic or Latino
(persons of Cuban, Mexican, Puerto Rican, South or
Central America or other Spanish culture race).

Not Hispanic or Latino
 

Indicate Source
Posting (internal)
Minority Vita Bank Advertisement
University Employee
Newspaper
Journal
Friend or Relative
Internet
Other

Are you currently employed by West Chester University?
Yes
No

West Chester University
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.