21193 Malta Road Equal Opportunity Employer

Kishwaukee CollegeApplication for Employment

21193 Malta Road Equal Opportunity Employer

Malta, IL 60150-9699

815-825-2086

It is the policy of Kishwaukee College not to tolerate sexual harassment in any form or to discriminate on basis race, color, religion or creed, sex, gender expression, national origin, ancestry, age, marital status, sexual orientation, arrest record, military status or unfavorable discharge from military service, citizenship status, use of lawful products while at work, physical or mental handicap or disability in its educational programs, activities or employment practices. Kishwaukee College complies with the Age Discrimination in Employment Act of 1975. Inquiries regarding compliance may be directed to the Director of Human Resources at Kishwaukee College.815-825-2086, ext. 2200.
If you are a qualified applicant with a disability and need reasonable accommodations to ensure an equal opportunity in applying for this position, please contact the Director of Human Resources at Kishwaukee College, 815-825-2086, ext. 2200 or or
815-825-2457 for TTY.

Note to Applicant: Only completed applications will be accepted. The information provided would become part of your official personnel file ifhired.

(Please Print)

Position(s) applied for: / ARE YOU SEEKING:
1. / F-T Employment P-T Employment Either
Specify days and hours if part-time:
M T W Th F Sat Sun
2. / HOURS: / ampm / to / ampm
Date: / Email Address:
Name:
Last First M.I.
Present Address:
Street City State Zip
(Include Area Code)
Telephone Number:
Are you legally authorized to work in the U.S.? / Yes / No
Have you worked at Kishwaukee College before? Yes No / If yes, when?
If hired, on what date will you be available to work?
(Include area code)
Present Employer: / Employer’s Telephone Number
Employer’s Address:
Street City State Zip
May we contact you at your place of employment? / Yes No / For Internal/HRUse Only:
Date Received ______
□Application
□EEO
□Letter of Introduction
□Resume
□Letters of Reference: 123
□Official Transcripts
□Unofficial transcripts
(Include Area Code)
Daytime Phone / Daytime available hours / a.m.p.m. / to / a.m.p.m.
(Include Area Code)
Evening Phone / Evening available hours / a.m.p.m. / to / a.m.p.m.
Rev. 6/2013

EDUCATION and TRAINING

HIGH SCHOOL/GED/OR EQUIVALENT

NAME OF SCHOOL

CITY

STATE

VOCATIONAL/TECHNICAL TRAINING (Business, Industrial, Military, etc.)

NAME OF SCHOOL

DESCRIPTION OF TRAINING

CITY / STATE
NAME OF SCHOOL /

DESCRIPTION OF TRAINING

CITY / STATE
NAME OF SCHOOL /

DESCRIPTION OF TRAINING

CITY

STATE

List any additional training that you believe may have a bearing on your qualifications for employment.

UNDERGRADUATE DEGREE (Include Community Colleges, etc.)

NAME OF COLLEGE/UNIVERSITY / DEGREE EARNED
CITY / STATE / MAJOR / MINOR / MINOR

NAME OF COLLEGE/UNIVERSITY

/ DEGREE EARNED
CITY / STATE / MAJOR / MINOR / MINOR
NAME OF COLLEGE/UNIVERSITY / DEGREE EARNED
CITY / STATE / MAJOR / MINOR / MINOR

GRADUATE DEGREE

NAME OF COLLEGE/UNIVERSITY / DEGREE EARNED
CITY / STATE / MAJOR / MINOR / MINOR

NAME OF COLLEGE/UNIVERSITY

DEGREE EARNED

CITY

STATE

MAJOR

MINOR

NAME OF COLLEGE/UNIVERSITY

DEGREE EARNED

CITY

STATE

MAJOR

MINOR

IF CURRENTLY ENROLLED, NAME OF SCHOOL & CITY

DEGREE SOUGHT

/ CREDITS EARNED TO DATE
Name of School / City

IF APPLYING FOR A FULL-TIME TEACHING POSITION, PLEASE SUMMARIZE COLLEGE AND UNIVERSITY WORK COMPLETED OR ENCLOSE A COPY OF TRANSCRIPT.

Subject

/ Undergraduate Hours / Graduate Hours / Subject / Undergraduate Hours / Graduate Hours

Total number of credit hours completed

OFFICE SKILLS INFORMATION (if applicable to position)

Word processing? / Yes No / Typing Speed (wpm)
Word processing program(s) (please list)
Spreadsheet application(s) (please list)
Office equipment used (please list)
Any special training/certifications (please list)

OTHER INFORMATION

LIST ANY PUBLICATIONS, ACADEMIC HONORS, OR PROFESSIONAL CERTIFICATIONS.
LIST SKILLS, TALENTS, OR INTERESTS THAT YOU FEEL MIGHT BE OF VALUE TO THE COLLEGE.
LIST ANY OTHER FACTORS WHICH QUALIFY YOU FOR THIS POSITION.

EXPERIENCE START WITH PRESENT OR MOST RECENT EMPLOYMENT.

1. PRESENT EMPLOYER

NAME OF FIRM OR SCHOOL*

/ EMPLOYMENT DATES (State Month and Year)
FROM: / TO:

COMPLETE ADDRESS OF FIRM OR SCHOOL*

CITY

/ STATE /

ZIP

SUPERVISOR’S NAME AND TITLE

/ TELEPHONE (include area code)
Full-time Part-time

POSITION

SALARY

REASON FOR LEAVING

SUBJECTS TAUGHT (if teaching position)
*MAY WE CONTACT THE ABOVE EMPLOYER? Yes No

NAME OF FIRM OR SCHOOL*

/ EMPLOYMENT DATES (State Month and Year)
FROM: / TO:

COMPLETE ADDRESS OF FIRM OR SCHOOL*

CITY

STATE

ZIP

SUPERVISOR’S NAME AND TITLE

/ TELEPHONE (include area code)
Full-time Part-time

POSITION

SALARY

REASON FOR LEAVING

SUBJECTS TAUGHT (if teaching position)
*MAY WE CONTACT THE ABOVE EMPLOYER? Yes No

NAME OF FIRM OR SCHOOL*

/ EMPLOYMENT DATES (State Month and Year)
FROM: / TO:

COMPLETE ADDRESS OF FIRM OR SCHOOL*

CITY

STATE

ZIP

SUPERVISOR’S NAME AND TITLE

/ TELEPHONE (include area code)
Full-time Part-time

POSITION

SALARY

REASON FOR LEAVING

SUBJECTS TAUGHT (if teaching position)
*MAY WE CONTACT THE ABOVE EMPLOYER? Yes No

NAME OF FIRM OR SCHOOL*

/ EMPLOYMENT DATES (State Month and Year)
FROM: / TO:

COMPLETE ADDRESS OF FIRM OR SCHOOL*

CITY

STATE

ZIP

SUPERVISOR’S NAME AND TITLE

/ TELEPHONE (include area code)
Full-time Part-time

POSITION

SALARY

REASON FOR LEAVING

SUBJECTS TAUGHT (if teaching position)
*MAY WE CONTACT THE ABOVE EMPLOYER? Yes No

PROFESSIONAL REFERENCES

INCLUDE AT LEAST TWO PEOPLE WHO HAVE HAD DIRECT CONTACT WITH YOUR PROFESSIONAL WORK. (EX. SUPERVISOR, DEPARTMENT CHAIRPERSON, CO-WORKER, ETC.)

NAME / POSITION / PLACE OF EMPLOYMENT / TELEPHONE (Include Area Code)

PERSONAL REFERENCES (NOT FORMER EMPLOYERS OR RELATIVES)

NAME / OCCUPATION / ADDRESS / TELEPHONE (Include Area Code)

I have carefully reviewed this application form and certify that the facts set forth in the employment application are accurate and complete. I understand that if the College employs me, any misrepresentation on this application will be sufficient cause for the termination of employment and/or immediate cancellation of any contract executed between the applicant and Kishwaukee College. I understand, however, that the College is not obligated to provide employment and that I am not obligated to accept employment. Nothing in this application is intended to create any contract of employment or to create any rights in the nature of a contract of employment. I understand that unless I am employed under an express written contract authorized by the Board of Trustees of Community College District #523, my employment with the College is at will and nothing shall restrict my right as an employee or the right of the College as an employer to terminate my employment at any time and for any reason. I understand and agree that all information furnished in this application may be verified by the College or its authorized representatives. I waive any right I may have to notice from any individuals and organizations named or referred to in this application prior to the release of any employment information to the College. I hereby authorize all individuals and organizations named or referred to in this application and any law enforcement organization to give the College all information relative to such verification and hereby release such individuals, organizations and the College from any and all liability for any claim or damage resulting therefrom.

I hereby acknowledge that I have read and understand the above statement.

Signature of ApplicantDate

Kishwaukee CollegeEqual Employment Opportunity

21193 Malta RoadInformation Request

Malta, IL 60150-9699

815/825-2086

THIS REQUEST WILL BE SEPARATED FROM THE EMPLOYMENT APPLICATION IMMEDIATELY UPON RECEIPT.

Kishwaukee College has a commitment to equal employment opportunity. In order to fulfill the opportunity and comply with federal and state agencies requirements, it is important to determine the composition of the applicant pool for each position.

The following information is helpful for the purpose of determining compliance with federal and civil rights law. The information will be confidential and will NOT be used to make a decision about your employment, nor will persons involved in the application process see it.

It is the policy of Kishwaukee College not to tolerate sexual harassment in any form or to discriminate on the basis race, color, religion or creed, sex, gender expression, national origin, ancestry, age, marital status, sexual orientation, arrest record, military status or unfavorable discharge from military service, citizenship status, use of lawful products while at work, physical or mental handicap or disability in its educational programs, activities or employment practices. Kishwaukee College complies with the age Discrimination in Employment Act of 1975. Inquiries regarding compliance may be directed to the Director of Human Resources at Kishwaukee College. (815) 825-2086 ext. 2200.

Name: (please print) / Date:
Position applied for:

A.Sex:Male Female

B.Marital Status: Single Married

C.Race/Ethnic identification (check one)

1. WHITE – (Not of Hispanic Origin)

A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

2. BLACK – (Not of Hispanic Origin)

A person having origins in any of the Black racial groups of Africa.

3. HISPANIC

A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin regardless of race.

4. ASIAN OR PACIFIC ISLANDER

A person having origins in any of the original peoples of the Far East, Southeast Asia, the Pacific Islands, or the Indian subcontinent. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.

5. AMERICAN INDIAN OR ALASKAN NATIVE

A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.

D.Are you over 40 years of age? Yes No

E.Do you have a disability? Yes No

(An individual with a disability is a person who has (1) a

physical or mental impairment that substantially limits one

or more major life activities; or (2) a record of such an impairment; or (3) is regarded as having such an impairment.)

F.How did you learn about this position? (check one)

Personal Contact

Newspaper announcement

Name of newspaper:

Placement service

Name of service:

Recruited by the College (“I was asked to apply by the appropriate College department, etc.”)

Walk-in (“I came on my own, seeking employment.”)

Other

06/2013

SURS ANNUITANT VERIFICATION FORM

Kishwaukee College

Human Resources

21193 Malta Road

Malta, IL 60150-9699

815-825-2086 ext. 3820 FAX: 815-825-2086

SURS ANNUITANT VERIFICATION FORM

Any college or university that employs an “affected annuitant”¹ is required to make contributions to the State Universities Retirement System (1-800-ASK-SURS or equal to the affected annuitant’s annualized retirement annuity (Public Act 97-0968). As a condition of your employment, you must verify that you are not an annuitant or an affected annuitant. You must also provide sufficient information to confirm your status.

Please answer the question(s) below and provide the information requested. This form and the requested information must be returned to Human Resources.

Have you ever been employed by a SURS employer?

No - Proceed to page 2, Verification section / Yes - Complete Questions 1 – 5

1. I AM / AM NOT (check the applicable answer) receiving a retirement annuity from SURS.

2. I WILL / WILL NOT (check the applicable answer) suspend my annuity payment from SURS.

3.I WILL / WILL NOT (check the applicable answer) become an “affected annuitant” as defined under SURS based on my current academic year employment or my anticipated employment in the academic year for which I am seeking employment by the College.

4.Do you currently work for another SURS entity? YES / NO (check the applicable answer).

If yes, please list the other SURS entities you are employed by.

5.Do you intend to work for another SURS entity in the academic year for which you are seeking employment by the College? YES / NO (Circle the applicable answer).

If yes, please list the other SURS entities you anticipate working for.

6.Are you an affected annuitant from a SURS entity? YES / NO (Circle the applicable answer).

If yes, please list the other SURS entities you have been employed at, as well as your pensionable wage used to determine your annuity.

If you are a current SURS annuitant who wants to work for or continue to work for Kishwaukee College you and have outside employment at another SURS institution, or if at any time during employment you become employed suspend your annuity you must notify the College immediately.
You may also elect to suspend your annuity. To take action, you must request the following form directly from SURS: “Election to Forego the Receipt of Annuity Payments during Reemployment.” The College recommends you receive counseling from SURS on the impact of filing this form and the temporary stoppage of your annuity payment. The Human Resources department must receive a copy of the form you have filed with SURS and receive verification from SURS regarding stoppage of payments and effective date. Upon receipt of the required information and documentation your employment may begin. During employment SURS will be deducted from your wages. As the annuitant you are responsible for contacting SURS regarding reinstating your annuity payment when employment ends.

An employee who knowingly makes a false statement, or falsifies or permits to be falsified any record or records in any attempt to mislead or defraud an employer with respect to employment of the annuitant may be guilty of a Class A misdemeanor and/or a Class 3 felony under the Illinois Pension Code.

Any omission or false statement regarding an employee’s SURS annuitant status or earnings will be referred by the College to SURS for notice to the local State’s Attorney’s Office for criminal prosecution under Section 15-186 and 1-135 of the Illinois Pension Code.

Verification

The information in this SURS Annuitant Verification Form is true, correct and complete to the best of my knowledge and belief. I understand that any misrepresentation or omission of fact, as stated or implied on this form is sufficient reason for not hiring me and will result in my immediate dismissal if already hired.

Signature:

Date:

Printed Name:

¹ [NOTE: A person receiving a retirement annuity from the System becomes an "affected annuitant" on the first day of the academic year following the academic year in which the annuitant first meets both of the following conditions:

(1) While receiving a retirement annuity under this Article, the annuitant has been employed on or after August 1, 2013 by one or more employers under this Article for a total of more than 18 paid weeks (which need not have been with the same employer or in the same academic year).

(2) While receiving a retirement annuity under this Article, the annuitant was employed on or after August 1, 2013 by one or more employers under this Article and received or became entitled to receive during an academic year compensation for that employment in excess of 40% of his or her highest annual earnings prior to retirement.

Paid weeks worked by an employed annuitant in which the annuitant is compensated solely from federal, foundation, trust, or corporate funds, or state grants in which the principal investigator is named are excluded from the paid weeks condition.]

Return this form to Kishwaukee College,

Director of Human Resources.