Position applying for:
Date Available:
Today's Date:
*Last Name:
*First Name:
Middle Initial:
*Street Address:
*City:
*State:
*Zip Code:
Home Phone:
Cell Phone:
Email Address:

Have you ever worked for LLC? No Yes If yes, please list: Year(s) and Position(s)

Are any of your education or past employment records under another name? No Yes If yes, please list name(s)

Do you have any relative(s) currently working for LLC? No Yes Relative Name Relative Position Held Relative Relationship

*Have you ever been convicted or plead guilty to any misdemeanor or felony in any state? No Yes If yes, please explain in detail the nature of the conviction or guilty plea (NOTE: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances, and the relevance of the offense to the position(s) applied for may, however, be considered.)

Institution 1 Name: City: State: Years Completed: Did you graduate? Yes No If yes, degree received:

Institution 2 Name: City: State: Years Completed: Did you graduate? Yes No If yes, degree received:

Institution 3 Name: City: State: Years Completed: Did you graduate? Yes No If yes, degree received:

Institution 4 Name: City: State: Years Completed: Did you graduate? Yes No If yes, degree received:

Please list any skills, talents or interests that you feel might be of value to the college.

Institution 1

Institution:
City:	State
Subjects & Level
Dates(years)

Institution 2

Institution:
City:	State
Subjects & Level
Dates(years)

Institution 3

Institution:
City:	State
Subjects & Level
Dates(years)

Institution 4

Institution:
City:	State
Subjects & Level
Dates(years)

Complete the section below if you served in the U.S. Armed Forces
Branch of Service
Length of Service
Rank/Pay Grade Upon Entrance At Discharge
Please list any special training and/or service schools attended

Please list employment, starting with present - or most recent - employer.

Employer 1 Position Title Beginning Date Ending Date Starting Pay Final Pay Employer's name Address Phone Supervisor Duties Reason for Leaving May we contact this employer? No Yes

Employer 2 Position Title Beginning Date Ending Date Starting Pay Final Pay Employer's name Address Phone Supervisor Duties Reason for Leaving May we contact this employer? No Yes

Employer 3 Position Title Beginning Date Ending Date Starting Pay Final Pay Employer's name Address Phone Supervisor Duties Reason for Leaving May we contact this employer? No Yes

Employer 4 Position Title Beginning Date Ending Date Starting Pay Final Pay Employer's name Address Phone Supervisor Duties Reason for Leaving May we contact this employer? No Yes

Are you on a lay-off and subject to recall? No Yes

How did you learn of this position?

References (Individuals who can judge your Professional/Academic/Technical Ability. Please do not list relatives, personal friends, neighbors, etc.)

Reference 1

*Name
Position
Address
City
State
Zip
*Phone

Reference 2

*Name
Position
Address
City
State
Zip
*Phone

Reference 3

*Name
Position
Address
City
State
Zip
*Phone

POLICY STATEMENT
Lake Land College is an Equal Opportunity Employer. We welcome you as an applicant for employment. Your application will be considered along with others in competition for the position(s) in which you express interest. It is the policy of Lake Land College to provide equality of opportunity in employment to all persons. This policy prohibits discrimination because of race, color, sex, religion, national origin, political affiliation, disability, age, or marital status in all aspects of the college's personnel policies, programs, practices, and operations. This policy applies to all phases of full-time, part-time, and temporary employment. All information contained or connected with this application will be considered personal and confidential and will be used only in conjunction with your consideration for employment.

PLEASE READ THE NEXT STATEMENT CAREFULLY
Federal law prohibits the employment of unauthorized aliens. Every person hired must complete an I-9 form, which is used to verify a person's right to work in the United States. Any offer of employment by Lake Land College is contingent upon the submission of satisfactory proof of identity and legal authorization to work in the United States. Failure to submit adequate proof of annuls any offer of employment by Lake Land College.

Public Act 85-827 states that an employee of a "State Agency" who is in default on an educational loan for six months or more, and in an amount of $600 or more, must make loan repayment arrangements as a condition of employment.

*Are you at this time in default on any educational loan(s)?

No Yes

If yes, and you are hired, written verification of satisfactory repayment arrangements must be provided within six months from the date of hire. Failure to provide adequate proof will result in termination of employment with Lake Land College.

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 false statement or misrepresentation on this application will be sufficient cause for dismissal/or immediate cancellation of any contract executed between the applicant and Lake Land 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 Lake Land College, 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 there from.

SURS ANNUITANT CERTIFICATION

I hereby certify that:

I am I am not

presently receiving an annuity from SURS.

If I am presently receiving an annuity from SURS, a history of my current and former employment with any SURS employer is attached. I understand that the College may require me to provide additional information and/or documentation regarding my employment history with SURS employers to ensure compliance with P.A. 97-968.

I verify that the above response is true and accurate. I acknowledge that providing false or inaccurate information may disqualify me from consideration for employment with the College.

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