Chadron State College

Human Resources

Application For Custodian

Please complete all items
Name
Last Name	First Name	Middle Name
E-mail and Phone Numbers (Include Area Code):
Cell Phone	Home Phone	Work Phone
E-Mail
Mailing Address
Street	City
State	Zip Code
Are you legally entitled to work in the U.S.? Yes No
Do you have a valid Driver's License? Yes No State Issued By:
Are you related to anyone employed by CSC? Yes No Employee Name:
Have you ever been employed by Chadron, Wayne, or Peru State College or the Nebraska State College System Office? Yes No When: Where:
Have you ever been convicted of a law violation or adjudicated under the jurisdiction of a juvenile court for an act that resulted in probation, community service, a jail sentence or revocation or suspension of your driver’s license? Answering yes isn’t an automatic disqualification; however, the information will be considered. Yes No If yes, please explain: Note: You are not obligated to disclose a sealed juvenile record of arrest, custody, complaint, disposition, diversion, adjudication, or sentence.
Are you 18 years of age or over? Yes No
Do you wish to claim Veteran's Preference? Yes No Please note, you may be required to submit substantiating documentation if you are selected as a finalist.
Position Applying For: Custodian
Type of Position Desired Full Time Part Time Temporary (i.e., adjunct faculty)
Salary Expected	Date Available:
General Information
List five references other than relatives who have knowledge of your skills and character.
1.Reference.
Name	E-Mail	Phone Number
How do you know this reference?
Reference's Address
Street	City
State	Zip Code
2.Reference.
Name	E-Mail	Phone Number
How do you know this reference?
Reference's Address
Street	City
State	Zip Code
3.Reference.
Name	E-Mail	Phone Number
How do you know this reference?
Reference's Address
Street	City
State	Zip Code
4.Reference.
Name	E-Mail	Phone Number
How do you know this reference?
Reference's Address
Street	City
State	Zip Code
5.Reference.
Name	E-Mail	Phone Number
How do you know this reference?
Reference's Address
Street	City
State	Zip Code

List all special skills and professional or occupational licenses/certifications:
Employment Record
Current or most recent position
1.
Company	Street Address
City	State	Zip Code
Immediate Supervisor	Phone:	Email:
Job Title	Full Time Part Time
Primary Duties
Reason for Leaving	May we contact your current employer? Yes No
Start Date of Employment	End Date of Employment
Starting Salary	Ending Salary
2.
Company	Street Address
City	State	Zip Code
Immediate Supervisor	Phone:	Email:
Job Title	Full Time Part Time
Primary Duties
Reason for Leaving
Start Date of Employment	End Date of Employment
Starting Salary	Ending Salary
3.
Company	Street Address
City	State	Zip Code
Immediate Supervisor	Phone:	Email:
Job Title	Full Time Part Time
Primary Duties
Reason for Leaving
Start Date of Employment	End Date of Employment
Starting Salary	Ending Salary
Educational Background
1.
School Name	Major Area of Study
Degree, Certification, Diploma Received or Expected Completion Date
School's Mailing Address
Street	City
State	Zip Code
2.
School Name	Major Area of Study
Degree, Certification, Diploma Received or Expected Completion Date
School's Mailing Address
Street	City
State	Zip Code
3.
School Name	Major Area of Study
Degree, Certification, Diploma Received or Expected Completion Date
School's Mailing Address
Street	City
State	Zip Code
4
School Name	Major Area of Study
Degree, Certification, Diploma Received or Expected Completion Date
School's Mailing Address
Street	City
State	Zip Code

Please read the following carefully before signing this application:
I attest to the accuracy and truthfulness of the information provided, and I understand that falsification or omission of any information on this application could result in my disqualification from further consideration in the selection process, or if hired, termination of my employment. I understand that consideration for employment is conditioned upon the results of a background check, and I authorize the Board of Trustees of the Nebraska State Colleges, the College and its agents or assigns to investigate all statements made by me on this application, to conduct a thorough investigation of my background and activities, and I agree to cooperate in such investigation and to release the Board of Trustees and its agents and assigns from all liability or responsibility and of all persons and corporations requesting or supplying such information. I authorize the Board of Trustees of the Nebraska State Colleges, the College and its agents and assigns to contact my cited references and any developed uncited references to make inquiries concerning my current and past employment. This authorization will expire six months from the date it is signed. A facsimile copy or electronic version of this document shall be considered as effective and valid as the original.
Please acknowledge the acceptance and understanding of the above statement by typing your name or initials in the "Applicant Signature" field. This form will not be accepted unless this portion is completed.
Applicant Signature	Date
Chadron State College is an equal opportunity institution. CSC does not discriminate against any student, employee or applicant on the basis of race, color, national origin, sex, disability, religion, or age in employment and education opportunities, including but not limited to admissions decisions. The College has designated an individual to coordinate the College’s non-discrimination efforts to comply with regulations implementing Title VI, VII, IX, and Section 504. Inquiries regarding non-discrimination policies and practices may be directed to: Kara Vogt, Title VI, VII, IX Compliance Coordinator Chadron State College, 1000 Main Street Chadron, NE 69337 Phone 308.432.6224
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