APPLICATION FOR EMPLOYMENT
Dixie State College is an Affirmative Action/Equal Opportunity/Equal Access Employer.
A separate application required for each position and accepted only for open positions.
COMPLETE EACH ITEM FULLY. Do not submit a resume in lieu of an application.
Position Desired:
Date:
Name:
Social Security No.:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Have you ever been employed by Dixie State College before? YES or NO
If yes, complete the following:
Position:
Department:
Dates:
List any relatives who have worked at Dixie State College and their relationship to you:
EDUCATION: (Attach transcripts or copies of diplomas, licenses and certificates if required)

(Select the highest year completed):
High School: Bus/Tech/Cmty/Jr. College:
College/University: Graduate School:
Degrees Earned (list highest first):
Degree:
Major emphasis:
Name of the Institution:
Location of the Institution:
Degree:
Major emphasis:
Name of the Institution:
Location of the Institution:
Degree:
Major emphasis:
Name of the Institution:
Location of the Institution:
List any special licenses, certificates or training you have received related to the position for which you are applying.
EXPERIENCE:
Beginning with your present or most recent experience, list four or more previous employers. (You may attach another sheet if necessary.)
Are you willing to have your present employer contacted regarding your qualifications?
YES or NO
Firm Name:
Supervisor:
Address:
Phone:
Job Title:
Dates:
Months Employed: Hours Worked per Week:
full-time: part-time: intership/volunteer:
Reason for Leaving:
Duties:
Firm Name:
Supervisor:
Address:
Phone:
Job Title:
Dates:
Months Employed: Hours Worked per Week:
full-time: part-time: intership/volunteer:
Reason for Leaving:
Duties:
Firm Name:
Supervisor:
Address:
Phone:
Job Title:
Dates:
Months Employed: Hours Worked per Week:
full-time: part-time: intership/volunteer:
Reason for Leaving:
Duties:
Firm Name:
Supervisor:
Address:
Phone:
Job Title:
Dates:
Months Employed: Hours Worked per Week:
full-time: part-time: intership/volunteer:
Reason for Leaving:
Duties:
Are you currently authorized to work in the United States (citizenship or appropriate visa)?    Yes No
In order for Dixie State College to protect its populace and property, applicants are required to answer the following question: Have you ever been convicted of a felony?   Yes No
If yes, you are required to complete an additional form, available at the Human Resources Office.
I certify that the statements made by me in this application are true, complete and correct to the best of my knowledge. I understand that false information made herein will result in disqualification or dismissal, if hired. I authorize Dixie State College to investigate all statements made and implied in this application. I also grant Dixie State College permission to contact references and previous employers, unless noted above. I understand that I may omit any information requested which I feel is illegally discriminatory in nature.

Signature: _____________________________