Submit by Email
Print Form
APPLICATION FOR EMPLOYMENT
RETURN TO: HUMAN RESOURCES
FLORIDA GATEWAY COLLEGE
149 S.E. COLLEGE PLACE
LAKE CITY, FLORIDA 32025-2007
(386) 754-4314 u www.fgc.edu
All sections of this application must be completed. Failure to sign or complete all sections of this application may result in your application being returned for
completion, causing delay or possible disqualification. Evidence of meeting the minimum qualifications must be clearly stated on the application.
Resumes or vita may be attached, but not in lieu of completing this application. Electronic submissions are required to be signed if hired.
Please type or complete in ink.
NAME (Print):
ADDRESS:
Last
First
Street
E-Mail Address:
Emergency contact:
Middle (not maiden)
City
Telephone:
Name
State
Zip
Home
Work
Relationship
Telephone
List any other names under which records of your education or work experience may be recorded:
Last
First
Middle (not maiden)
NAME(S) (Print):
POSITION APPLYING FOR:
❏ Full-time
❏ Part-time
EDUCATION: Please list ALL institutions attended.
SCHOOLS
GRADUATE High School
Yes ❏
No ❏
GED ❏
Junior/
Community
College(s)
Yes ❏
No ❏
College(s)/
University(s)
Yes ❏
No ❏
Graduate/
Professional
Yes ❏
No ❏
Other (Specify):
Yes ❏
No ❏
NAME & ADDRESS OF SCHOOL
DATES ATTENDED
LICENSURE, REGISTRATION, CERTIFICATION (if position requires)
License, Registration or Certification Number
Date Received
Expiration Date
Semester/
Quarter Hours
Major/
Minor
Degree
SKILLS: List other skills you possess and believe relevant to
the position you seek, such as fluency in language(s) other than
English; computer skills; computer software knowledge; etc.
(Approved agency test scores may be required).
Applications are accepted only when a vacancy is available. Application materials cannot be returned and
the information is subject to verification.
TRANSCRIPTS: During the application process, photocopies of transcripts should be submitted.
Foreign transcripts must include an official translation and evaluation. If hired, the college requires
official transcripts from each postsecondary institution attended.
EXPERIENCE
Please read carefully before starting. List all employment starting with the present or most recent employer.
Account for all periods, including unemployment and service with the armed forces. Also, include relevant
voluntary and/or part-time work experience. Resumes are acceptable for the description of duties and
responsibilities only. Explain any gaps in employment. If needed, attach additional sheet using the same
format as on this application.
1. Name of Employer
Telephone
Name & Title of Supervisor
Address (Include City, State, & Zip Code)
Employed From
Mo/Yr
________
To
Mo/Yr
Position Title
Reason for Leaving
________
Describe Job Responsibilities
May employer be contacted
at this time?
____ Yes
____ No
2. Name of Employer
Name & Title of Supervisor
Telephone
Address (Include City, State, & Zip Code)
Employed From
Mo/Yr
________
To
Mo/Yr
Position Title
Reason for Leaving
________
Describe Job Responsibilities
May employer be contacted
at this time?
____ Yes
____ No
3. Name of Employer
Name & Title of Supervisor
Telephone
Address (Include City, State, & Zip Code)
Employed From
Mo/Yr
________
To
Mo/Yr
Position Title
Reason for Leaving
________
Describe Job Responsibilities
May employer be contacted
at this time?
____ Yes
____ No
4. Name of Employer
Telephone
Name & Title of Supervisor
Address (Include City, State, & Zip Code)
Employed From
Mo/Yr
________
To
Mo/Yr
Position Title
Reason for Leaving
________
Describe Job Responsibilities
May employer be contacted
at this time?
____Yes
____ No
5. Name of Employer
Name & Title of Supervisor
Telephone
Address (Include City, State, & Zip Code)
Employed From
Mo/Yr
________
To
Mo/Yr
Position Title
Reason for Leaving
________
Describe Job Responsibilities
May employer be contacted
at this time?
____ Yes
____ No
6. Name of Employer
Name & Title of Supervisor
Telephone
Address (Include City, State, & Zip Code)
Employed From
Mo/Yr
________
To
Mo/Yr
Position Title
Reason for Leaving
________
Describe Job Responsibilities
May employer be contacted
at this time?
____ Yes
____ No
REFERENCES: List three (3) individuals (not relatives) who are willing to serve as a professional or personal
reference for you. Please include persons who know your personal, employment, and educational backgrounds. Include name, title, organization, and current telephone number for each.
1.
Name
Title
Organization
Phone
2.
Name
Title
Organization
Phone
3.
Name
Title
Organization
Phone
MISCELLANEOUS INFORMATION
Have you ever been convicted of or fined and/or sentenced for any criminal offense (misdemeanor or felony), or have you ever
plead guilty or ‘no contest’ (nolo contendere), or had adjudication of guilt withheld for any criminal offense (misdemeanor or felony)?
 Yes
 No
If yes, give dates and places of any convictions, pleas, fines and/or sentences, and explain or describe them. ( Attach separate sheet.) NOTE: A conviction will not necessarily disqualify you from employment. Factors such as the seriousness and nature of the offense, age at time of the offense, and rehabilitation will also be taken into account.
Are you currently on probation, parole, or under charges for violation of a law?
 No
 Yes
Have you ever been terminated or asked to resign from any job? If yes, please provide the date, position, and an explanation of the  No
circumstances.  Yes
Are you now or have you been employed by Florida Gateway College?
If yes; dates and department.
 Yes
 No
Do you have any relatives employed at Florida Gateway College? If yes, give names, title and or position:
 Yes
 No
State
Driver License #
 Yes  No
Do you have a valid driver’s license?
If yes, give State and Driver’s License number.
Are you retired from any Florida state administered retirement plan?  Yes
 No
If yes, please state which plan and date of retirement.
EXEMPTION FROM PUBLIC RECORDS DISCLOSURE
ARE YOU A CURRENT OR FORMER LAW ENFORCEMENT OFFICER, OTHER EMPLOYEE** OR THE SPOUSE OR CHILD OF
ONE, WHO IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE UNDER §119.07, F.S.?
 Yes
 No
**Other covered jobs include: correctional and correctional probation officers, firefighters, certain judges, assistant state attorneys, state attorneys, assistant and statewide prosecutors, personnel or the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or child support enforcement, and certain investigators in the Department of Children and Families (see §119.07, F.S.).
❏
❏
APPLICANT’S STATEMENT
I understand that this application will be given every consideration, but is not a promise of employment.
I understand that the College may investigate my driving and criminal record. I give the College the right to investigate all references
and to secure additional information about me, if job related. I hereby release the College and its representatives from liability for
seeking information, and release all other persons, corporations, or organizations for furnishing such information. I further understand that if
hired I will be fingerprinted and a criminal background check will be performed.
I understand that, should I be employed, such employment will be on a probationary period of six months from the first date of employment.
I understand that any employment relationship with the College is of an “at will” nature, which means that the employee may resign at
any time and the College may discharge employees at any time with or without cause. This relationship may be modified by provisions
contained in an employment contract.
I agree to abide by all rules and policies established by the District Board of Trustees of Florida Gateway College. I understand
that FGC maintains a drug free campus and that the unlawful manufacture, distribution, dispensation, possession, or use of alcohol
or any other controlled substance will result in disciplinary action up to and including termination of employment.
I hereby state that all of the information that I provide on this application, on my personal resume, transcripts, or other application materials, and
in any interview is true and accurate. I understand that if I am employed and any such information is later found to have been omitted, falsified, or misleading in any respect, I may be dismissed.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT
Signature of Applicant
Date
FGC does not discriminate in education or employment related decisions on the basis of race, color, religion, national origin, gender, age,
disability, marital status, genetic information, or any other legally protected status in accordance with the law. The Equity Officer is
Sharon Best, Director of Human Resources, 149 SE College Place, Lake City, FL 32025, and may be reached at (386) 754-4313.
Printed 07/10
VETERANS’ PREFERENCE
(Complete only if claiming veterans’ preference)
Yes
No
Do you wish to claim veterans’ preference?
(If yes, you must attach your DD214 to this form.) If you have questions about veterans’ preference, see the HR
Office.
Veterans’ preference will be given to eligible veterans and spouses of veterans in initial appointment to non-exempt
Career Service positions. Listed below are the four veterans’ preference categories. If eligible, please check which
Veterans’ preference category you are claiming.
1. A veteran with a service-connected disability who is eligible for or receiving compensation, disability retirement,
or pension under public laws administered by the US Veterans’ Administration and the Department of Defense.
Or
2. The spouse of a veteran who cannot qualify for employment because of a total and permanent disability, or the
spouse of a veteran missing in action, captured of forcibly detained by a foreign power.
Or
3. The veteran of any war who has served on active duty for one day or more during a wartime period (see *
below) excluding active duty for training and who was discharged under honorable conditions from the Armed Forces
of the United States of America.
Or
4. The un-remarried widow or widower of a veteran who died of a service-connected disability.
A DD214 or comparable document, which serves as a certificate of release or discharge claim, must be furnished at
the time of application. In addition, applicants claiming categories 1, 2, or 4 must furnish supporting documentation in
accordance with the provisions of Rule 55A-7.013 F.A.C. Wartime periods are defined in F.S. 1.01(14). Under
Florida law, preference in appointment shall be given by the state to those persons in categories 1 and 2 and then
those in 3 and 4. Veteran’s preference does not apply to retired-for-longevity military personnel when a competitive
examination in used. However, retired military personnel with a compensable disability are eligible.
If an applicant claiming veterans’ preference for a vacant position is not selected, he/she may file a complaint with the
Department of Veterans’ Affairs, PO Box 31003, St. Petersburg, FL 33731. A complaint must be filed within 21 days
of the applicant receiving notice of the hiring decision made by the employing agency or within 3 months of the date
the application is filed with the employer, if no notice is given.
This Veterans’ Preference Claim is a supplement to the employment application of Florida Gateway College and
is made on a voluntary basis. The information provided will be kept confidential in accordance with the Americans
with Disabilities Act. If veterans’ preference is being claimed, this form must be returned to Human Resources at the
time of application with all necessary documentation.
* Effective July 1, 2007, SB 156, Veterans Defined/Wartime Service, redefines the term “veteran” to include
active military, naval, or air service during Operation Enduring Freedom or Operation Iraqi Freedom. This is an
amendment to subsection 1.01(14), Florida Statues. This law qualified veterans for wartime service eligibility
who have served honorably but who have not met the criteria for the award of a campaign or expeditionary
medal. The service dates are defined as follows:
Operation Enduring Freedom – October 7, 2001 to date to be determined
Operation Iraqi Freedom – March 19, 2003 to date to be determined
SignatureofApplicantclaimingVeterans’Preference
Date
EQUAL OPPORTUNITY ADDENDUM
Applicants are considered for all positions for which they meet minimum qualifications, and the College
provides equal opportunities to all persons without regard to race, color, religion, national origin, gender,
age, disability, marital status, genetic information, or any other legally protected status in accordance with the law.
Governmental agencies require periodic reports on the sex, ethnicity and disability. This data is for
analysis and affirmative action only and will not become a part of the application file.
YOU ARE INVITED TO COMPLETE THE FOLLOWING INFORMATION. SUBMISSION IS VOLUNTARY.
THANK YOU.
CHECK ONE:
FEMALE
MALE
ARE YOU HISPANIC/LATINO?
YES
NO
CHECK ONE OR MORE OF THE FOLLOWING:
WHITE
BLACK OR
AFRICAN AMERICAN
NATIVE HAWAIIAN OR
OTHER PACIFIC ISLANDER
REFERRAL:
AMERICAN INDIAN/
ALASKAN NATIVE
How were you referred to Florida Gateway College?
Announcement
Friend
ASIAN
Self
College Website
where
Public Agency
Newspaper
name
Other
Internet
Florida Gateway College does not discriminate in education or employment related decisions on the basis of race, color,
religion, national origin, gender, age, disability, marital status, genetic information, or any other legally protected status in
accordance with the law. The Equity Officer is Sharon Best, Director of Human Resources, 149 SE College Place,
Lake City, FL 32025, and may be reached at 386.754.4313.
Rev. 09/2011
Florida Retirement System (FRS) - Certification Form
This form is not an offer of employment or an enrollment form. If hired, a Retirement Choice kit may be mailed to your home with an enrollment form.
Name
SSN
Agency Name
Previous FRS Employer
PLEASE COMPLETE SECTION I, II, III, OR IV
I.
I have never been a member of a State of Florida administered retirement plan.
STOP HERE
SIGNATURE
DATE
II. I was a member of the following State of Florida administered retirement plan (also complete Section III or IV) 1
FRS Pension Plan (incl. DROP)
FRS Investment Plan
State University System Optional Retirement Program (SUSORP)
State Community College Optional Retirement Program (SCCORP)
Senior Management Service Optional Annuity Program (SMSOAP)
Other
III. I am not retired from any State of Florida administered retirement plan. I understand that if it is later
determined that I was a retiree and was reemployed during the first 6 calendar months after I retired or
th
after my DROP termination date, or at any time during the 7 through 12 months after I retired or after
my DROP termination date, I must repay all unauthorized benefits received (see Section IV for details),
or, if in the Investment Plan, terminate my employment. My employer may also be liable for repaying
any unauthorized benefits I received.
SIGNATURE
DATE
IV. I am retired from a State of Florida administered retirement plan. My FRS Pension Plan retirement effective date, DROP termination date, or date I received my first distribution from the FRS Investment
Plan, SUSORP, SCCORP, SMSOAP, or other plan was ______________________.
If I am initially reemployed by an FRS-covered employer on or after July 1, 2010, I will not be permitted to participate in a State of Florida administered retirement plan to earn an additional
retirement benefit.
I understand that as a Pension Plan retiree:
2
a. If I am employed by an FRS-covered employer in any type of position during the first 6 calendar
months after I retired or after my DROP termination date, my retirement and DROP status are
3
voided, all retirement and DROP benefits I received must be repaid, and I must reapply for
retirement in order to receive future benefits.
th
th
b. If I am reemployed by an FRS-covered employer at any time during the 7 through the 12 months
after I retired or after my DROP termination date, my monthly retirement benefit must be
4
3
suspended and any unauthorized benefits received must be repaid. My employer may also be
liable for repaying any unauthorized benefits I received.
I understand that as an Investment Plan retiree:
2
a. If I am employed by an FRS-covered employer in any type of position during the first 6 calendar
3
months after I retired, I must repay any benefits received or terminate employment for an
additional period to satisfy the 6 calendar month termination requirement.
th
th
b. If I am reemployed by an FRS-covered employer at any time during the 7 through the 12 months
after my retirement, I will not be eligible for additional distributions until I terminate employment or
4
complete 12 calendar months of retirement.
SIGNATURE
Retiree Definition
You are considered
retired if:
1. You have received any benefits under the
FRS Pension
Plan (including
DROP), or
2. You have taken
any distribution
(including a rollover) from the
FRS Investment
Plan, or alternative retirement
programs offered
by state universities (SUSORP),
state community
colleges
(SCCORP), state
government for
senior managers
(SMSOAP), or
local governments for senior
managers.
DATE
1
If you are not retired and earned FRS service after certain periods in 2002 (depending on your employer), you must rejoin the FRS retirement plan you were enrolled in when you
terminated FRS-covered employment. You may have a one-time 2nd Election to switch FRS retirement plans. Also, alternative retirement programs are available to certain employees. Contact your employer for deadline and other information.
2
Positions include OPS, temporary, seasonal, substitute teachers, part-time, full-time, regularly established, etc.
3
Florida law requires a return of all unauthorized Pension Plan benefit payments or Investment Plan distributions received by a member who has violated the FRS termination or
reemployment provisions. Similar provisions apply to unauthorized SUSORP, SCCORP, or other state-administered plan distributions – contact that plan’s administrator for details.
4
There are no reemployment exemptions/exceptions for Pension Plan members whose effective date of retirement or DROP termination date is on or after July 1, 2010 or Investment Plan members who retire on or after July 1, 2010.
CERT
Revised 06-2011
EMPLOYERS: RETAIN THIS FORM IN THE EMPLOYEE’S PERSONNEL FILE. DO NOT SEND THIS FORM TO THE FRS, UNLESS REQUESTED.
Notification of Social Security Number
Collection and Usage
In compliance with FL Statute 119.071(5), this document serves to notify you of the purpose for the collection and usage of
your Social Security number.
Florida Gateway College (FGC) collects and uses your social security number only for the following purposes in
performance of the College’s duties and responsibilities. To protect your identity, FGC will secure your SSN from
unauthorized access, never release your SSN to unauthorized parties, and assign you a unique student/employee identification
number. This unique ID number is used for all associated employment and educational purposes at FGC.
Admissions Department
Federal legislation relating to the Hope Tax Credit requires that all postsecondary institutions report student SSN’s to the
Internal Revenue Service (IRS). This IRS requirement makes it necessary for community colleges to collect the SSN of
every student. A student may refuse to disclose his or her SSN to the college, but the IRS is then authorized to fine the
student $50.00.
In addition to the federal reporting requirements, the public school system in Florida uses SSN’s as a student identifier
(section 229.559, Florida Statutes-new school code section 1008.386). In a seamless
K-20 system, it is beneficial for postsecondary institutions to have access to the same information for the purpose of tracking
and assisting students in the smooth transition from one education level to the next. All SSN’s are protected by federal
regulations - Family Educational Rights and Privacy Act (FERPA) and are NEVER released to unauthorized parties.
Registrar’s Office
Your SSN is used for legitimate business purposes, as set forth below. All SSNs are protected by federal regulations of the
Family Educational Rights and Privacy Act (FERPA) and are NEVER released to unauthorized parties.
• Completing and processing enrollment certification for students applying for Veterans benefits (Veterans
Administration)
• Verifying identification on transcripts for evaluation and award of transfer credit
Human Resources Department
Your SSN is used for legitimate business purposes in compliance with:
• Completing and processing the Federal I-9 (Department of Homeland Security)
• Completing and processing Federal W4, W2, W9, 1099 (Internal Revenue Service)
• Completing and processing Federal Social Security taxes (FICA)
• Processing and distributing Federal W2 (Internal Revenue Service)
• Completing and processing quarterly Unemployment Reports (FL Dept. of Revenue)
• Completing and processing Florida Retirement Contributions reports (FL Dept. of Retirement)
• Completing and processing Workers Compensation claims (FCCRMC and Department of Labor)
• Direct Deposit Files
• New Hire Information Report (FL Department of Revenue)
• Completing and processing 403(b) and 457(b) Contribution reports and FICA Alternative enrollment
• Completing and processing group health, life, and dental coverage enrollment and census reports
• Completing and processing various supplemental insurance deduction reports
• Background checks – necessary for accurate identification for screening through the Florida Department of Law
Enforcement (FDLE)
• Work Study work assignments
Providing your Social Security number is a condition of employment at FGC.
I understand the above information and have been given a copy of this document.
__________________________________________
Name of Student/Employee (please print)
__________________________________________
Signature
__________________
Date
Rev. 3/11
State and Federal Statutes and Regulations
Mandating or Authorizing the Use of Social Security Numbers
Department
Use of SS Numbers
Authorized or
Mandated
Authorized
Admissions
Student identifier in K-20
system / Generation of
college student identifier
Admissions/ Financial Aid
Hope Tax Credit –Federal
Forms 1098t, 8863
Mandated
Admissions
Federal I-9 / Citizenship
Status
Waiver of Release
Mandated
Authorized
FAFSA Free Application for
Federal Student Aid; Federal
Mandated
Authorized
Disabilities Services
Financial Aid
Work Study Program;
Federal Plus /Direct
Loans; Emergency Short
Term Loan
Financial Aid
State grants and
scholarships
Background checks,
Federal Form I-9
Authorized
Human Resources
Employment Tax
Reporting
Human
Resources/Financial Aid
Federal W2, W4, W5,
1099, 1042, FICA
Mandated
Work Study Assignments
Mandated
Human Resources
Employment
Florida Directory of New
Hires reports
Mandated
Human Resources
Workers Compensation
Mandated
Human Resources
Unemployment Reports
Mandated
Human Resources
Benefits
Florida Retirement
Contributions
Mandated
Authorized
Human Resources
Benefits
Health Benefits, Life,
Dental, & Supplement Ins.
Processing
403(b) and 457(b)
Contribution Report &
FICA Enrollment
Direct Deposit Files
Authorized
Human Resources
Employment
Human Resources
Benefits
Human Resources
Mandated
Authorized
Statute or Regulation
Florida Statute: 119.071(5);
1008.386,1002.22(2) , and State Board
of Education Rule 6A – 1.0955.
Florida Assessment and
Accountability, FS1008.386; Florida
Public Records, 119.071(5)(a)2.a(II),
Taxpayer Relief Act of 1997 (Pub.L.
No 105-34. 111 Stat 788) TRA ’97;
IRC 6109; Florida Public Records, FS
119.071(5)(a)6.b
Dept of Homeland Security 8 U SCA
FL Stat 132.4a
Florida Public Records, FS 119.07
(5)(a)2.a.(II)
Higher Education Act of 1965, as
amended, Sections 441-448, 483 and
484(p) 20 USC 1091(p), 20 USC
1078-2(f); Code of Federal
Regulations, 34 CFR 668.32(i),
668.36; CFR 668.16, 34, 26CFR
1.6050
FS1009.22 and 1009.23; Florida
Public Records, FS 119.071(5)(a)6.b;
Immigration & Control Act of 1986,
8 USC 1324a; FL Dept of Law
Enforcement, FS943.0542;
FS 119.071(5)(a)2.a(II)
Internal Revenue Code. sections 14411443, 3402(f)(2)(A), 6109
and 6051(a)(2)
Internal Revenue Code. sections 14411443, 3402(f)(2)(A), 6109
and 605(a)(2)
Florida Social and Economic
Assistance, FS 409.2576(3); Personal
Responsibility and Work Opportunity
Reconciliation Act of 1996, USC
653a
Florida Workers Compensation,
FS 440.185(2)(b)
FL Unemployment Compensation
Law, FS443.091(1)(g), FCCRMC
FL Retirement System, FS 121.071(3);
FL public Records,
FS 119.071(5)(a)6.g
FL Public Records,
FS 119.071(5)(a)6.f
Required
US Tax Code 501(c)(3)
Required
FS 119.071(5)(a)
Purchasing
Vendor Federal W-9
Mandated
Registrar
Test Center
Veterans Benefits
Assessment and
Accountability Testing
Industry Licensure and
National Registry
Mandated
Authorized
Authorized
Florida Public Records,
FS 119.071(5)(a)6.b
Agency for Workforce
Innovation-Reporting
Agency for Workforce
Innovation - Reporting
Authorized
Florida Public Records, FS
119.071(5)(a)6.b
Florida Public Records, FS
119.071(5)(a)6.b
Florida State Board of
Nursing - Licensure
Mandated
Florida Public Records, FS
119.071(5)(a)6.b
Florida State Board of
Physical Therapy Practice
Licensure
Mandated
Florida Public Records, FS
119.071(5)(a)6.b
Florida Department of
Health Licensure
Mandated
Florida Public Records, FS
119.071(5)(a)6.b
Industrial-Welding and
HVAC
Banner Center for Water
Resources
Global Logistics Banner
Center Workforce
Programs-Reporting
Nursing Programs
Workforce Programs/State
Licensure
Physical Therapy
Assistant Program
Workforce Programs/State
Licensure
Emergency Medical
Services Workforce
Programs/State Licensure
Law Enforcement/
Corrections Programs
Workforce
Programs/FDLE Identity
Screening
Educator Preparation
Institute
Cosmetology
Workforce Programs/State
Licensure
Community Based Jobs
Training Grant
Workforce Programs
Authorized
Internal Revenue Code, sections 14411443, 3402(f)(2)(A), 6109 and
6051(a)(2); Title 26 US Code
38USC 3471
FS 1008.386
Florida Department of Law
Enforcement (FDLE)
background criminal
history checks
MandatedCJSTC-67 and
67A forms
Florida Public Records, FS
119.071(5)(a)6.b; Florida Department
of Law Enforcement, FS 943.14, FS
943.2565
Florida Department of
Education - Teacher
Certification
Florida Department of
Business and Professional
Regulations - Licensure
Department of Labor
Mandated CT-133 form
Florida Public Records, FS
119.071(5)(a)6.b
Mandated
Florida Public Records, FS
119.071(5)(a)6.b
Authorized
Florida Public Records, FS
119.071(5)(a)6.b