ࡱ> %` ޱbjbjNN .,,m((((t),D+411111|\3@4tCCCCCCC$kEhGTC41144C11oD9994:11C94C99:X:,:1+ 0{&{(4.: ;D0D: 'H5l'H:'H:x44944444CC9444D4444$(( Verified by HR:Date:HIRING UNIT MUST COMPLETE FOR PROCESSING:Hiring Unit: FORMTEXT      Chancellor/VC : FORMCHECKBOX  Chancellor  FORMCHECKBOX  Academic Affrs  FORMCHECKBOX  Admin  FORMCHECKBOX  Student Affrs  FORMCHECKBOX  Univ RelationsPosition: FORMTEXT      Posting FY#: FORMTEXT    -  FORMTEXT     Contact: FORMTEXT      Phone: FORMTEXT      APPLICANT DATA COLLECTION FORMAdministrative & 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:):  FORMTEXT      (first): FORMTEXT      (m.i.): FORMTEXT   Social Security Number: FORMTEXT     -  FORMTEXT    -  FORMTEXT     Previous Name(s): FORMTEXT      Home Street Address: FORMTEXT      City, State & Zip: FORMTEXT      Home Phone No.: FORMTEXT      Personal E-mail: FORMTEXT      Business Street Address: FORMTEXT      City, State & Zip: FORMTEXT      Business Phone No.: FORMTEXT      Business E-mail: FORMTEXT      Educational History Name of InstitutionLocation (City, State)Dates of Attendance From (Mo/Yr) to (Mo/Yr)Degree Earned  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Academic Specialization:Undergraduate:Major fields of Study: FORMTEXT      Minor fields of Study: FORMTEXT      Graduate:Major fields of Study: FORMTEXT      Other fields of Advanced Study: FORMTEXT      Thesis Subject:For Master's Degree: FORMTEXT      Committee Members: FORMTEXT      For Doctor's Degree: FORMTEXT      Committee Members: FORMTEXT      ***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:  FORMTEXT      (Please include or attach a separate list if necessary.)Publications & Papers Read at Professional Meetings: FORMTEXT      (Please attach a separate list.)Professional Licensure: FORMTEXT      (Please attach legible copies of all current professional licenses.)4/08 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. 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FORMCHECKBOX  YES (please provide an explanation including date, offense, city, and state.) b.  FORMCHECKBOX  NO May we contact your current employer?  FORMCHECKBOX  YES  FORMCHECKBOX  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. 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