"Application for Employment" - Missouri

Application for Employment is a legal document that was released by the Missouri Department of Higher Education - a government authority operating within Missouri.

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STATE OF MISSOURI
Please type or print in ink. Your application must be
APPLICATION FOR EMPLOYMENT
completed in its entirety to be considered.
“AN EQUAL OPPORTUNITY EMPLOYER”
www.dhe.mo.gov
IDENTIFICATION
SOCIAL SECURITY NUMBER
NAME (LAST, FIRST, MIDDLE)
MAILING ADDRESS
TELEPHONE NUMBER (INCLUDE AREA CODE)
ZIP CODE
CITY
STATE
TITLE OF POSITION(S) APPLIED FOR
COUNTY AND STATE OF LEGAL RESIDENCE
COUNTRY
EDUCATION AND TRAINING: ALL APPLICANTS MUST COMPLETE
CIRCLE
HIGHEST YEAR
TYPE OF SCHOOL
NAME OF SCHOOL
CITY AND STATE
COMPLETED
GRADUATED
STARTING DATE ENDING DATE
MAJOR/MINOR
Yes  No 
9
10
11
12
XXXX
High School/GED
XXXX
XXXX
GED 
Obtained Degree?
1
2
3
4
College
Yes  No 
Obtained Degree?
1
2
3
4
College
Yes  No 
Obtained Degree?
1
2
3
4
Graduate School
Yes  No 
Business or
Obtained Degree?
1
2
3
4
Vo-Tech School
Yes  No 
Correspondence
or Night School
COURSES TAKEN
If college credit is earned but no degree, indicate total number of credit hours earned. ____________________
How many additional credit hours do you need to receive your degree? ________________________________
Indicate any special courses or training programs not reported above that relate to the type of employment you are seeking.
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Indicate and explain any work-related skills or experience you have obtained through unpaid work, volunteer work, skills developed as a hobby, etc.
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
COPY OF COLLEGE TRANSCRIPTS, CERTIFICATES, LICENSES MUST BE ATTACHED
MILITARY RECORD: ALL APPLICANTS MUST COMPLETE
If you are a male between 18 and 26 years of age, have you registered with the Selective Service System? Yes  No 
Have you ever served in the U.S. Military Service?
Yes  No 
If yes: a) Are you an honorable discharge veteran? Yes  No 
b) State branch and period of active service?
______________________________________________________________________________________________________________________
(Branch)
(Period of Active Service)
NOTE:A dishonorable or general discharge is not an absolute bar to employment and other factors will affect the final decision regarding employment.
SPECIAL SKILLS - CLERICAL: ONLY CLERICAL APPLICANTS ARE REQUIRED TO COMPLETE THIS SECTION
Check any of the following skills that you have, based on training or experience:
 Applications: Spreadsheet/Database
 Word Processing
 Telephone/Receptionist
 10-Key Data Entry
 Bookkeeping
 Shorthand/Transcription
 Typewriter (WPM) _____________
 Other ________________________
STATE OF MISSOURI
Please type or print in ink. Your application must be
APPLICATION FOR EMPLOYMENT
completed in its entirety to be considered.
“AN EQUAL OPPORTUNITY EMPLOYER”
www.dhe.mo.gov
IDENTIFICATION
SOCIAL SECURITY NUMBER
NAME (LAST, FIRST, MIDDLE)
MAILING ADDRESS
TELEPHONE NUMBER (INCLUDE AREA CODE)
ZIP CODE
CITY
STATE
TITLE OF POSITION(S) APPLIED FOR
COUNTY AND STATE OF LEGAL RESIDENCE
COUNTRY
EDUCATION AND TRAINING: ALL APPLICANTS MUST COMPLETE
CIRCLE
HIGHEST YEAR
TYPE OF SCHOOL
NAME OF SCHOOL
CITY AND STATE
COMPLETED
GRADUATED
STARTING DATE ENDING DATE
MAJOR/MINOR
Yes  No 
9
10
11
12
XXXX
High School/GED
XXXX
XXXX
GED 
Obtained Degree?
1
2
3
4
College
Yes  No 
Obtained Degree?
1
2
3
4
College
Yes  No 
Obtained Degree?
1
2
3
4
Graduate School
Yes  No 
Business or
Obtained Degree?
1
2
3
4
Vo-Tech School
Yes  No 
Correspondence
or Night School
COURSES TAKEN
If college credit is earned but no degree, indicate total number of credit hours earned. ____________________
How many additional credit hours do you need to receive your degree? ________________________________
Indicate any special courses or training programs not reported above that relate to the type of employment you are seeking.
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Indicate and explain any work-related skills or experience you have obtained through unpaid work, volunteer work, skills developed as a hobby, etc.
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
COPY OF COLLEGE TRANSCRIPTS, CERTIFICATES, LICENSES MUST BE ATTACHED
MILITARY RECORD: ALL APPLICANTS MUST COMPLETE
If you are a male between 18 and 26 years of age, have you registered with the Selective Service System? Yes  No 
Have you ever served in the U.S. Military Service?
Yes  No 
If yes: a) Are you an honorable discharge veteran? Yes  No 
b) State branch and period of active service?
______________________________________________________________________________________________________________________
(Branch)
(Period of Active Service)
NOTE:A dishonorable or general discharge is not an absolute bar to employment and other factors will affect the final decision regarding employment.
SPECIAL SKILLS - CLERICAL: ONLY CLERICAL APPLICANTS ARE REQUIRED TO COMPLETE THIS SECTION
Check any of the following skills that you have, based on training or experience:
 Applications: Spreadsheet/Database
 Word Processing
 Telephone/Receptionist
 10-Key Data Entry
 Bookkeeping
 Shorthand/Transcription
 Typewriter (WPM) _____________
 Other ________________________
EMPLOYMENT HISTORY (List previous employment beginning with your present or most recent employer)
DATES EMPLOYED (Month and Year)
Describe Duties of Job ___________________________________________
_____________________________________________________________
EMPLOYER
_____________________________________________________________________________________________
SUPERVISOR (Name and Title)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
EMPLOYER ADDRESS
______________________________________________________________________________________________
CITY, STATE AND ZIP
______________________________________________________________________________________________
JOB TITLE
MONTHLY SALARY
______________________________________________________________________________________________
_____________________________________________________________________________________________
REASON FOR LEAVING
_____________________________________________________________
DATES EMPLOYED (Month and Year)
Describe Duties of Job ___________________________________________
_____________________________________________________________
EMPLOYER
_____________________________________________________________________________________________
SUPERVISOR (Name and Title)
_____________________________________________________________________________________________
EMPLOYER ADDRESS
_____________________________________________________________________________________________
______________________________________________________________________________________________
CITY, STATE AND ZIP
______________________________________________________________________________________________
JOB TITLE
MONTHLY SALARY
______________________________________________________________________________________________
_____________________________________________________________________________________________
REASON FOR LEAVING
_____________________________________________________________
DATES EMPLOYED (Month and Year)
Describe Duties of Job ___________________________________________
_____________________________________________________________
EMPLOYER
_____________________________________________________________________________________________
SUPERVISOR (Name and Title)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
EMPLOYER ADDRESS
______________________________________________________________________________________________
CITY, STATE AND ZIP
______________________________________________________________________________________________
JOB TITLE
MONTHLY SALARY
______________________________________________________________________________________________
_____________________________________________________________________________________________
REASON FOR LEAVING
_____________________________________________________________
DATES EMPLOYED (Month and Year)
Describe Duties of Job ___________________________________________
_____________________________________________________________
EMPLOYER
_____________________________________________________________________________________________
SUPERVISOR (Name and Title)
_____________________________________________________________________________________________
EMPLOYER ADDRESS
_____________________________________________________________________________________________
______________________________________________________________________________________________
CITY, STATE AND ZIP
______________________________________________________________________________________________
JOB TITLE
MONTHLY SALARY
______________________________________________________________________________________________
_____________________________________________________________________________________________
REASON FOR LEAVING
_____________________________________________________________
BUSINESS REFERENCE (Please provide a list of business references requested below)
RELATIONSHIP WITH CONTACT
LENGTH OF TIME
NAME
COMPANY ORGANIZATION
TITLE
TELEPHONE NUMBER
ADDRESS (City, State, Zip)
RELATIONSHIP WITH CONTACT
LENGTH OF TIME
NAME
COMPANY ORGANIZATION
TITLE
ADDRESS (City, State, Zip)
TELEPHONE NUMBER
RELATIONSHIP WITH CONTACT
LENGTH OF TIME
NAME
COMPANY ORGANIZATION
TITLE
ADDRESS (City, State, Zip)
TELEPHONE NUMBER
RELATIONSHIP WITH CONTACT
LENGTH OF TIME
NAME
COMPANY ORGANIZATION
TITLE
ADDRESS (City, State, Zip)
TELEPHONE NUMBER
DEFAULT STATUS
PERSONAL DATA
A. Do you (or your spouse) have any relative(s) employed by this department?
 YES
 NO
If yes, give name(s) and relationship(s) ________________________________________________________________________________________
B. Have you ever been convicted of a felony?
 YES
 NO
List all such cases in the “Remarks” section and in each case give:
1. The date, court, and county location;
2. The nature (type) of offense or violation (stealing, burglary, etc.);
3. The penalty imposed (disposition)
Conviction of a violation of the law is not an automatic bar to employment. Each case is considered on its individual merits; however, falsification of the
application will result in disqualification. (Suspended execution of a sentence is a conviction.)
C. Are you authorized to work in the U.S.?
 YES
 NO
If not a citizen, can you submit verification that you are lawfully available for employment in this country?
 YES
 NO
D. Are you willing to travel if position requires it?
 YES
 NO
E. Do you possess a valid driver’s license?
 YES
 NO
REMARKS
ESTIMATED START DATE
If your application is considered favorably, on what date will you be available to work? _____________________________________
INDICATE TYPE(S) OF EMPLOYMENT YOU WILL ACCEPT
 Full-Time (Ongoing in nature, 40 hours per week)
 Permanent Part-Time (Ongoing position, which works less than 40 hours per week)
 Temporary (Hired on an as-needed basis)
 Intern (College student with semester hours hired to work mid-May - August, or between semester breaks)
 Summer Student
 Emergency (Hired based on sporadic needs)
APPLICANT’S SIGNATURE AUTHORIZING TO RELEASE INFORMATION
I hereby request and authorize you to furnish the Missouri Department of Higher Education with any and all information they may request concerning my employment record,
criminal record, education record, military record, and status on student loans. This authorization is specifically intended to include any and all information of a confidential or
privileged nature as well as photocopies of such documents, if requested. The information will be used for the purpose of determining my eligibility for employment with the
Missouri Department of Higher Education.
I hereby release you and your organization from any liability, which would result from furnishing the information requested above or from any subsequent use of such
information in determining my qualifications to serve as an employee of the Missouri Department of Higher Education.
I understand that my application will be active for six months and, upon my request, is renewable for an additional six months. I certify that the information provided herein
is true and complete to the best of my knowledge. I understand misrepresentation or omission of information on this application and/or inserts, including relatives working
for the department, educational attainments, work history, professional credentials, criminal history, etc. is cause for rejection of my application or subsequent dismissal
from employment.
SOCIAL SECURITY NUMBER
APPLICANT’S PRINTED NAME
If you were previously employed under a different name(s), please specify ________________________________________________________________
DATE
APPLICANT’S SIGNATURE
MDHE OFFICE USE ONLY
On _________________________ a system check was completed by MDHE staff to determine if ______________________________________________
was in default status on any students loan(s) guaranteed by our agency. This check determined that the employee listed above is not currently in default on
any loan.
SIGNATURE OF PERSON PERFORMING CHECK
DATE
Mark box when completed
 DRIVING RECORD
 BACKGROUND CHECK
DIRECTOR OF ADMINISTRATION
DATE
PLEASE ATTACH RESUME WITH APPLICATION
STATE OF MISSOURI
DEPARTMENT OF HIGHER EDUCATION
HUMAN RESOURCES
AFFIRMATIVE ACTION SURVEY
The following requested information is VOLUNTARY and in no way affects you as an individual applicant. This data will assist the department in analyzing
affirmative action statistics.
NOTE: This portion of the application will be removed and retained separate from the application files.
INSTRUCTIONS
Please fill in your Social Security Number in the spaces provided below. Select the correct number in each question below. Place your numbered answer to
each question in the space indicated by the arrow. Return this form with your application for employment.
SOCIAL SECURITY
NUMBER
A. What sex are you?
1. Male
2. Female
B. What is the highest level of education you have attained?
1. 0 - 8 years
2. 9 - 12 years but not a high school graduate
3. High school graduate (or passed GED test)
4. Post high school vocational or business school training
5. College, less than B.A. or B.S. degree
6. B.A., or B.S., or comparable bachelor’s degree
7. M.A., or M.S., or comparable master’s degree
8. PhD, JD, LLB, or comparable professional degree
9. MD, or comparable professional degree in medicine
C. Of the following, which racial/ ethnic group do you consider yourself a member?
W = White
H = Hispanic or Latino
B = Black or African American
A = Asian
NH or OPI = Native Hawaiian or Other Pacific Islander
AI or AN = American Indian or Alaska Native
M = Multiracial ( Two or more races)
E. How did you learn about this position?
1. MDHE web site
6. Radio
2. Missouri State Division of Employment Security
7. Television
3. Other state agency
8. Newspaper or periodical
4. Friend
9. School
5. State employee
10. Other
F.
Do you have a physical or mental disability which does not prevent employment, but which should
be considered in job placement? If you do, indicate the area of impairment.
1. No disability
5. Epilepsy
9. Mental
2. Sight
6. Diabetes
10. Other
3. Hearing
7. Cardiac
4. Amputee
8. Partial Paralysis
RETURN THIS FORM TO THE
Missouri Department of Higher Education
Attn: Human Resources
P.O. Box 1469
Jefferson City, MO 65102-1469
WITH THE APPLICATION FOR EMPLOYMENT
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