Full-time Staff: Student Success Coordinator

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Current Address: *

Are you able to provide documentation of legal authorization to work in the United States? *

What is your availability/desired schedule? *

(please check all that apply)

If seeking part-time employment, what number of hours per week can you work? * Select answer N/A Up to 10 hours Up to 20 hours Up to 30 hours Up to 40 hours

EDUCATION RECORD: Do you have a High School Diploma or GED? *

Provide High School details

Please provide high school name, address, major, credits earned or degree conferred

EDUCATION RECORD: Select the credentials you have earned *

Please check all that apply.

College/University Details

Please provide college/university name, address, major, credits earned or degree conferred.

Certificate or Licensure Details

Please provide name, address, license or certificate

EMPLOYMENT HISTORY 1.a. Employer Name, Address and Phone *

Please provide information for all employment within the past 10 years, starting with the most recent employer. Account for all periods including unemployment and service in the armed forces. Do not substitute a resume for this section.

1.b. Job Title *

1.c. Dates of Employment *

1.d. Supervisor *

1.e. Major Duties *

1.f. Job type (FT/PT) *

1.g. Final Salary *

1.h Reason for Leaving *

EMPLOYMENT HISTORY 2.a. Employer Name, Address and Phone *

Please provide information for all employment within the past 10 years, starting with the most recent employer. Account for all periods including unemployment and service in the armed forces. Do not substitute a resume for this section.

2.b. Job Title *

2.c. Dates of Employment *

2.d. Supervisor *

2.e. Major Duties *

2.f. Job type (FT/PT) *

2.g. Final Salary *

2.h. Reason for Leaving *

EMPLOYMENT HISTORY 3.a. Employer Name, Address and Phone *

Please provide information for all employment within the past 10 years, starting with the most recent employer. Account for all periods including unemployment and service in the armed forces. Do not substitute a resume for this section.

3.b. Job Title *

3.c. Dates of Employment *

3.d. Supervisor *

3.e. Major Duties *

3.f. Job type (FT/PT) *

3.g. Final Salary *

3.h. Reason for Leaving *

SUPPLEMENTAL INFORMATION - Use this section to show evidence of meeting the qualifications for the position or providing information you would like to add for consideration.

Provide general Job-Relevant Information AND Computer Hardware and/or Software; Other Tools and Equipment.

Have you previously been employed by Lakeland? *

If yes, please list:

Please list Position, Department and Dates.

The College does not permit the employment of relatives within the same administrative unit (generally defined as reporting to the same supervisor, manager, or administrator).

Please list any of your relatives who are employed at the college. *

REFERENCE 1: Provide PROFESSIONAL/WORK references from positions held within the last ten years. *

Include these details for each of your references: Name, Company, Position, Address, Telephone Number, Email Address, Work Relationship, No. of years known, and may we contact this individual.

REFERENCE 2: Provide PROFESSIONAL/WORK references from positions held within the last ten years. *

Include these details for each of your references: Name, Company, Position, Address, Telephone Number, Email Address, Work Relationship, No. of years known, and may we contact this individual.

REFERENCE 3: Provide PROFESSIONAL/WORK references from positions held within the last ten years. *

Include these details for each of your references: Name, Company, Position, Address, Telephone Number, Email Address, Work Relationship, No. of years known, and may we contact this individual.

Are you currently authorized to work lawfully in the United States of America? *

Do you now or will you in the future require employment visa sponsorship to continue working in the United States? *

By checking this box, I acknowledge that I have read and understand the statements listed below. *

The following statement is a part of the application. Read carefully before signing.

I certify that the answers I have made to all of the questions in this application are true and complete to the best of my knowledge. I understand that any material omission, misrepresentation or falsification of this information is sufficient cause for rejection of my application or termination of my employment.

I understand that any offer of employment is conditional upon proof of legal authorization to work in the United States as required by the Immigration Reform and Control Act.

I hereby authorize representatives of Lakeland Community College to obtain background information about me including but not limited to verification of education, investigation of present and past employment, and review of criminal convictions. I also give consent for representatives of Lakeland Community College to obtain a Driver’s Abstract Report from a state in which I have held a standard or commercial driver’s license in the past five years if driving is an essential function of the position. I understand that I may be considered ineligible for employment if my driving record does not meet the standards of Lakeland Community College and/or its insurer. I release Lakeland Community College and its representatives from liability for seeking such information and all sources for furnishing such information.

When submitting this application electronically, checking the box is an acceptable substitute for your signature.

Lakeland Community College is an equal access and equal opportunity employer. We have a strong commitment to the principle of diversity and, in that spirit, seek a broad spectrum of candidates including women, minorities, people with disabilities and people over 40. Under-represented groups are encouraged to apply. If your disability requires special accommodations to participate in the application/interview process, contact the Human Resources Office at 440-525-7575.

Please type your full name *

Date *