Verified by HR:
Date:
HIRING UNIT MUST COMPLETE FOR PROCESSING:
Hiring Unit:
Chancellor/VC :	Chancellor Academic Affrs Admin Student Affrs Univ Relations
Position:	Posting FY#:	-
Contact:	Phone:
APPLICANT DATA COLLECTION FORM
Administrative & Professional Staff. Faculty, & Graduate Assistants

(This form is required prior to offering employment or a graduate assistantship to an applicant.)

Instructions: Type or print in ink - signature required on reverse side - you may provide a resume or vita to supplement this form.
Name:	(last:):	(first):	(m.i.):
Previous Name(s):
Home Street Address:
City, State & Zip:
Home Phone No.:	Personal E-mail:
Business Street Address:
City, State & Zip:
Business Phone No.:	Business E-mail:

Educational History

Name of Institution	Location (City, State)	Dates of Attendance

From (Mo/Yr) to (Mo/Yr)	Degree

Earned

Academic Specialization:
Undergraduate:	Major fields of Study:
Minor fields of Study:
Graduate:	Major fields of Study:
Other fields of Advanced Study:
Thesis Subject:	For Master's Degree:
Committee Members:
For Doctor's Degree:
Committee Members:
***NOTE: An official degree-bearing transcript of your highest accredited degree will be required for employment. It must be sent directly to SIUE from the institution which granted the degree.***
Current Memberships in Professional & Civic Organizations:
(Please include or attach a separate list if necessary.)
Publications & Papers Read at Professional Meetings:
(Please attach a separate list.)
Professional Licensure:
(Please attach legible copies of all current professional licenses.)
Employment History: List below your experience, beginning with your present or most recent position. Describe each position separately, emphasizing your professional, supervisory and committee duties. Give special attention to experience relating to the position for which you are applying. Attach additional sheets as necessary.
Employer:	Employed From:	To:	Total Time:
Complete Address:
Ending Salary:	Your Title/Rank:
Reason for Leaving:
Specific Duties:
Supervisor's Name

& Phone No.:
Employer:	Employed From:	To:	Total Time:
Complete Address:
Ending Salary:	Your Title/Rank:
Reason for Leaving:
Specific Duties:
Supervisor's Name & Phone No.:
Employer:	Employed From:	To:	Total Time:
Complete Address:
Ending Salary:	Your Title/Rank:
Reason for Leaving:
Specific Duties:
Supervisor's Name & Phone No.:

ALL APPLICANTS MUST COMPLETE BEFORE BEING CONSIDERED FOR EMPLOYMENT:

Have you ever been convicted of a misdemeanor or felony, or pleaded no contest?

a. YES (please provide an explanation including date, offense, city, and state.)

b. NO

May we contact your current employer?

YES

NO

Certification of Applicant: The statements that I have made in this application, including all other materials submitted for consideration, are true and complete to the best of my knowledge, and I understand that any alteration or concealment of a material fact will result in my disqualification before appointment or dismissal after appointment. I hereby authorize Southern Illinois University Edwardsville and its representatives to investigate my background. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information, and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release Southern Illinois University from any and all liability which may be incurred as a result of collecting and considering such information. I understand that all reference responses are confidential and are not available to my inspection.
Date:
Signature of Applicant:
The SIUE Annual Security and Fire Safety Report is available online at http://www.siue.edu/securityreport . The report contains campus safety and security information, crime statistics, fire safety policies, and fire statistics for the previous three calendar years. This report is published in compliance with Federal law, titled the “Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act” and the Higher Education Opportunity Act also known as the “Campus Fire Safety Right to Know.” For those without computer access, a paper copy of the report may be obtained, with a 24-hour notice, from the Office of the Vice Chancellor for Administration, Rendleman Hall, Room 2228, 618-650-2536.

5/13 – previous versions are obsolete

Verified by HR:

OIT

2013-05-07

Joyree Chura

SIUE