NEO A&M Employment Appication Revised 07.01.141

APPLICATION FOR EMPLOYMENT (PRE-EMPLOYMENT QUESTIONNAIRE)

Directions: Answer all questions which are applicable. Please do not state ‘’See Resume”.

PERSONAL INFORMATIONName (First, MI, Last) Social Security #

Present Address City State Zip

Permanent Address City State Zip

Phone # Cell # E-mail

Have you ever been convicted of a felony? Yes No If so when

If hired can you show proof of your legal right to work in the U.S.? Yes No(Please direct questions to the human resources department at NEO.)

Are you at least 18 years old? Yes No

Have you ever been employed by NEO A&M? Yes No If yes, from to

Job Title(s):

Are you related to any NEO A&M employee? Yes No

If yes, name: Relationship: Location:

How did you hear about this position? NEO Bulletin Board OK Emp Security Commission Employee NEO Website Newspaper Other, please specify

NORThEASTERN OkLAhOMA A&M COLLEgE • 200 I Street NE, Miami, OK 74354-6497 • (918) 542-8441www.neo.edu

NEO A&M Employment Appication Revised 07.01.142

EMPLOYMENT INFORMATION

1. Position for which you are applying

2. Desired Salary

3. If offered a position, when can you report for work?

4. Please indicate available shifts: Day Night Evening Weekends

5. Have you applied to NEO A&M College before? Yes No When?

6. Are you currently employed? Yes No If yes, please complete the information below.

Employer’s Name Phone #

Street Address Start Date

City, State, and Zip End Date

List jobs you held, duties performed, skills used or learned, advancements or promotions:

Supervisor’s Name Starting Salary

Ending Salary

Reason for leaving:

May we contact your current employer? Yes No NEO A&M College is an affirmative action equal opportunity employer.

EMPLOYMENT EXPERIENCEExcluding current employer from front page, please provide employment history.A resume may be attached, but will not be accepted in lieu of completing the employment record.

Employer’s Name Phone #

Street Address Start Date

City, State, and Zip End Date

List jobs you held, duties performed, skills used or learned, advancements or promotions:

Supervisor’s Name Starting Salary

Ending Salary

Reason for leaving:

JOb #1

NEO A&M Employment Appication Revised 07.01.143

Employer’s Name Phone #

Street Address Start Date

City, State, and Zip End Date

List jobs you held, duties performed, skills used or learned, advancements or promotions:

Supervisor’s Name Starting Salary

Ending Salary

Reason for leaving:

Employer’s Name Phone #

Street Address Start Date

City, State, and Zip End Date

List jobs you held, duties performed, skills used or learned, advancements or promotions:

Supervisor’s Name Starting Salary

Ending Salary

Reason for leaving:

JOb #2

JOb #3

PLEASE EXPLAIN gAPS IN EMPLOYMENT:

NEO A&M Employment Appication Revised 07.01.144

ADDITIONAL EXPERIENCE

Special Skills

U.S. Military or Naval Services

Rank Present Membership in National Guard or Reserves

Honorable Discharge? Yes No

REFERENCES PROVIDE THREE PROFESSIONAL REFERENCES (i.e. co-workers, customers, and/or supervisors)

Name & Address Phone Number Relationship Years Aquainted

I hereby authorize the employers and references listed herein to release information regarding me

on this application is true and complete. I agree that:*If any false information, omissions or misrepresentations are discovered at any time, my employment may be terminated. *I authorize NEO to investigate my background, references, employment record, and other matters related to mysuitability for employment.* This may include a criminal background check and a check on my driving record.* Any offer of employment is made subject to the NEO personnel policies and conditioned upon my continuedcompliance therewith throughout my employment.* NEO is an ‘’at will’’ employer - employment and compensation can be terminated without cause and without prior notice. * The terms and conditions of my employment may be changed without cause and without prior notice.* I understand that employment into a driving position is dependent upon a safe driving record.* I have a history of demonstrating ethical and professional behavior.

APPLICANT SIGNATURE DATE

EDUCATION NAME & LOCATION GRADUATE? DEGREE MAJOR/SUBJECTS OF STUDY

High School Diploma or GED

Undergraduate Education

College or University

Graduate Studies

Graduate Studies

Trade School or Specialized Training

Special Study, Research Work, or Other Training

CREDENTIALS (Do not include those that include race, color, origin, sex, age, or religious beliefs.)

NAME NUMBER EXPIRATION DATE

Other Credentials

Professional Memberships

NEO A&M Employment Appication Revised 07.01.145

NORTHEASTERN OKLAHOMA A&M COLLEGE - 200 I. STREET NE - MIAMI, OK 74354-6497Memorandum for: Applicants

Voluntary Request for EEO InformationThis information is requested of all applicants on a voluntary basis. This company is a government contractor. As a result of this coverage, we must comply with Federal and State Equal Employment Opportunity record keeping and reporting requirements. To respond to these obligations, we must request the following information. PLEASE NOTE: Submission of this information is VOLUNTARY and refusal to provide it will not subject you to any adverse action. The information you give us will be kept CONFIDENTIAL and away from your employment application. The information may only be used in accordance with the provisions of applicable laws, executive orders and regulations, including those that require the information to be summarized and reported to the federal government

Name: Job Applied for: ______________________________

I decline this opportunity respond to the questions listed below:

GENDER Male FemaleRACE/ETHNICITY - PLEASE CHOOSE ONE OF THE FOLLOWING: American Indian or Alaskan Native: A person having origins in any of the peoples of North and South America (including Central America), and who

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: A person having origins in any of the black racial groups of Africa.

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.

Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

Two or More Races:

Are you a U.S. Citizen? Yes NoDo you wish to declare yourself as mentally or physically disabled? Yes No(If yes, please answer below.)

Description of Disability:

Skill or procedures you use or would intend to use to perform the job in spite of the disability

Accommodation which could be made that would enable you to perform the job properly and safely:

regulations may be informed.

NEO A&M Employment Appication Revised 07.01.146

MILITARY SERVICE: This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002,38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take

A “DISABLED VETERAN” is one of the following: - a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or

- a person who was discharged or released from active duty because of a service-connected disability.

A “RECENTLY SEPARATED VETERAN” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.

An “ACTIVE DUTY WARTIME OR CAMPAIGN BADGE VETERAN” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An “ARMED FORCES SERVICE MEDAL VETERAN” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box above and below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE I AM NOT A PROTECTED VETERAN

Signature: Date:

NEO A&M Employment Appication Revised 07.01.147

Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act

President G.H. Bush signed the student Right-to-Know and Crime Awareness and Campus Security Act of 1990 into law on November 8, 1990 into law on November 8, 1990. The Act requires all postsecondary instiutions participating in Federal Student Aid Programs to disclose campus security policies and certain crime statistics on a yearly basis to current as well as prospective students, faculty and employees.

Such information for Northeastern Oklahoma A&M College is reported and maintained in the Annual Campus Security Report that is linked below.

This report includes statistics for the previous three years concerning reported crimes that occurred on-campus; in certain off-campus buildings or property owned or controlled by NEO; and on public property within, or immediately adjacent to an accessible from the campus. The report also includes institutional policies concerning campus security, such as policies concerning sexual assault, and other means. A copy of this report is available by contacting Rebecca Long, Campus Police. To contact via e-mail rebecca.long@neo.edu, or you can call (918) 540-6373.

To view the full text of this act, as well as statistics, please visit: http://neo.edu/StudentLife/Services/CampusPoliceMap

To apply for employment at NEO A&M College, print our Employment Application. Once you have manually completed the form, you may submit your application in person (200 I. Street NE; Miami, OK 74354) ng a copy to the following address:, by e-mail to randall.qualls@neo.edu, or by maili

NEO A&M CollegeAttn: Randy Qualls, Human Resources200 I. Street NEMiami, OK 74354