Sc 1 Form – Fill Out and Use This PDF

CALIFORNIA STATE UNIVERSITY, LONG BEACH

	FOR FACULTY AND ACADEMIC- RELATED POSITIONS		SC- 1
	STATEMENT OF PROFESSIONAL PREPARATION AND EXPERIENCE		FORM
	POSITION APPLYING FOR
	DEPARTMENT NAME

P E R S O N A L D A T A

LAST NAME	FIRST NAME	MIDDLE NAME
ADDRESS	STREET	APARTMENT NUMBER
CITY	STATE	ZIP CODE
SOCIAL SECURITY NUMBER	HOME/ WORK PHONE NUMBER	E- MAIL

ALL OFFERS OF EMPLOYMENT ARE CONDITIONAL UPON SATISFACTORY PROOF OF AN APPLICANT’S IDENTITY AND LEGAL ABILITY TO WORK IN THE UNITED STATES AT THE TIME OF EMPLOYMENT.

ARE YOU CURRENTLY AUTHORIZED TO WORK IN THE U.S.?		9 YES	9 NO
DO YOU HAVE RELATIVES WORKING FOR THE UNIVERSITY?		9 YES	9 NO
IF YES, PLEASE GIVE THE FOLLOWING INFORMATION.
NAME	RELATIONSHIP		DEPARTMENT
WERE YOU EVER DISCHARGED FROM ANY EMPLOYMENT?		9 YES	9 NO
IF YES, PLEASE EXPLAIIN FULLY BELOW.

CONVICTION RECORD

HAVE YOU EVER BEEN COVICTED OF ANY FELONY OFFENSE?9 YES9 NO

IF YES, PLEASE LIST THE CIRCUMSTANCES, PLACES AND DATES.

[DO NOT LIST ANY OFFENSE THAT OCCURRED PRIOR TO YOUR 18TH BIRTHDAY, WHICH WAS HANDLED OR SEALED BY A JUVENILE COURT.]

OVER |

ACADEMIC PERSONNEL

REVISED JUNE 14, 2002

EDUCATION - HIGHEST DEGREE MUST BE LISTED

CITY & STATE LOCATION

YEARS ATTENDED

DEGREE, IF ANY, &

MO/ DAY/ YR

NAME OF INSTITUTION

DEGREE

[LIST FOREIGN COUNTRY]

FROM – TO

SUBJECT MAJOR

OBTAINED

EMPLOYMENT RECORD

EXPERIENCE IN TEACHING & OTHER EMPLOYMENT. LIST CURRENT POSITION FIRST.

POSITION/ TITLE

FULL TIME OR

EMPLOYER

CITY & STATE LOCATION

& / OR

PART TIME

DATES OF EMPLOYMENT

ACADEMIC RANK

EMPLOYMENT

PUBLICATIONS, HONORS & AWARDS

OTHER RELEVANT EXPERIENCE [INCLUDE VOLUNTEER WORK]

ATTENTION! PLEASE READ CAREFULLY BEFORE SIGNING.

Your signat ure af f irm s that all inf orm ation on this applicat ion is true to the best of your knowledge.

I cert ify that the statem ents m ade by m e on t his application are t ruthful and accurat e, and in the event that any of the st atem ents are f alse, I understand t hat I will be subject to dism issal.

SIGNATURE

DATE

CALIFORNIA STATE UNIVERSITY, LONG BEACH does not discrim inat e on t he basis of disabilit y against ot herwise qualified disabled applicant s. CSULB will m ake reasonable accom m odat ion t o applicant s wit h ident ified disabilit ies. If you need accom m odat ion in t he pre- em ploym ent select ion process (applicat ions, t est s, int erviews, et c.), please cont act t he chair of t he depart m ent t o which you have applied . In addit ion t o m eet ing fully it s obligat ions of nondiscrim inat ion under federal and st at e law, CSULB is com m it t ed t o creat ing a com m unit y in which a diverse populat ion can live and work in an at m osphere of t olerance, civilit y, and respect for t he right s and sensibilit ies of each individual, wit hout regard t o econom ic st at us, et hnic background, polit ical views, sex ual orient at ion, or ot her personal charact erist ics or beliefs. Copies of t he Universit y's Annual Cam pus Crim e Report are available upon request . To request a copy, cont act t he Universit y Police Depart m ent at (562) 985 - 8535 or t hrough t heir web sit e ht t p:/ / www.upd .csulb .edu, or by writ ing t o: CSULB Universit y Police Dept . 1331 Palo Verde Ave., Long Beach, CA 90840, At t n: Crim e Prevent ion.

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