PRIOR WORK EXPERIENCE COLLECTION FORM FOR UNIVERSITY FACULTY
Please provide information regarding service in collegiate teaching, paid academic research, paid post-doctoral research, and academic administration experience prior to hiring. This includes all sabbatical leave periods and conscripted military service from such institutions, and all academic administration and/or university approved research experience. Do not include graduate assistantships, teaching assistantships, research assistantships, or other work related to your area of study undertaken at or for an institution while you were a graduate student. All fields must be completed for each entry. Attach additional sheets if necessary.
| Job Title or Teaching Discipline |
Academic Rank | Institution | Years in Rank Beginning Mo/Yr |
Ending Mo/Yr |
Percent of Full-Time |
Total Collegiate Experience (to be completed by campus): ________
Please provide information regarding service in community/technical college teaching, counseling, librarianships, and academic administration. All fields must be completed. Attach additional sheets if necessary. Report actual, not weighted, years of experience.
| Job Title or Teaching Discipline |
Institution | Beginning Mo/Yr | Ending Mo/Yr | Percent of Full-Time |
Total Community/Technical College Experience (to be completed by campus--list actual years): _________
Please provide professional-level experience at elementary and secondary schools. All fields must be completed. Attach additional sheets if necessary. Report actual, not weighted, years of experience.
| Job Title or Grade(s) Taught | Institution | Beginning Mo/Yr | Ending Mo/Yr | Percent of Full-Time |
Total Elementary/Secondary Experience (to be completed by campus--list actual years): _________
Please provide information regarding other professional-level experience in business, industry, government, military, or other areas that is directly related to your faculty assignment. All fields must be completed. Attach additional sheets if necessary. Report actual, not weighted, years of experience.
| Job Title/Description | Institution/Employer | Beginning Mo/Yr | Ending Mo/Yr | Percent of Full-Time |
Total Other Related Experience (to be completed by campus--list actual years): _________
I attest that all statements and representations set forth above are true and accurate. Inaccurate statements or misrepresentations concerning my work experience may lead the University to take one or more of the following actions: withdrawal of an offer of employment; modification of starting salary; and, in the event that I become an employee, disciplinary action up to and including discharge.
Name:__________________ Signature:________________________ Date:__________________
Evaluator #1: ______________ Evaluator #2: __________________ Date:__________________