FA Student Application for Employment

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Student Employment Application

Semester you can begin employment*

Student ID #*

Name*

First Name

Last Name

Email*

Contact Phone*

Permanent Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Intended Major/Field of Study*

Are you legally eligible for employment in the USA?*

Yes No

Have you been employed by ICC previously?*

Yes No

Have you ever been convicted of or plead "no contest" to a felony, misdemeanor or criminal offense?*

Yes No

I am available to work:*

Do you have reliable transportation to commute off campus?*

Yes No

Education & Involvement

Name of High School (or equivalent provider):*

Where did you attend/complete high school requirements:*

City

State

ZIP Code

Do you want to let employers know about any involvement in extra curricular activities?*

Yes No

Extracurricular Activities:

Employment History

Have you previously been employed?*

Yes No

How many previous employers have you had? *

List maximum of 3

Employer 1 Name*

Name of Supervisor

Employer Phone

Employer Location*

City

State

ZIP Code

Employer 2 Name*

Name of Supervisor

Employer Phone

Employer Location*

City

State

ZIP Code

Employer 3 Name*

Name of Supervisor

Employer Phone

Employer Location*

City

State

ZIP Code

Student Signature*

[clear]

Use your mouse or finger to draw your signature above

* By my signature, I certify the information I have provided is accurate, true and complete. I authorize ICC to use any means it deems fit to verify this information.

* I understand that if I am employed by ICC, that my work is seasonal and/or temporary, and I may be dismissed for any reason at any time with or without notice. Also, if I am employed, I agree to: show up on time and work my prescribed schedule; to work in a law-abiding manner; to perform work as directed by my college supervisor; and to make reasonable accomodations with my supervisor when I need to be absent from work. I also understand that a list of all college policies and procedures are available to me from the Office of Human Resources.

*I understand that as a student worker, I am not eligible for any college benefits and that I do not qualify for unemployment benefits based on my position as a student worker at ICC. I also understand that the money I earn as a student worker may effect the level of financial aid I am eligible to receive.

Applicants for admission and employment, students, parents, employees, sources of referral of applicants for admission and employment and all unions or professional organizations holding negotiated agreements or professional agreements with the institution are hereby notified that this institution does not discriminate on the basis of race, religion, color, national origin, sex, age or disability in admission or access to, or treatment or employment in its programs and activities. Any person having inquiries concerning Independence Community College's compliance with the regulations implementing Title VI, Title IX and the Americans with Disability Act of 1990 is directed to contact the coordinators who have been designated to coordinate the educational institution's efforts to comply with the regulations implementing these laws.