Fillable Inforamtion Reference Sheet - Carteret Community College printable pdf download

INFORMATION & REFERENCE SHEET

Carteret Community College

President Candidate

Name: _______________________/________________________/______________________

Last

First

Middle

Please list all other names by which you are known on any educational, business, or legal records:

_______________________________________________/_____________________________________________

Current Position:____________________________________________________Number of Years_____________

College or Organization: _____________________________________________ Number of Years_____________

Other Most Recent Senior-Level Administration Positions & Organizations:

_______________________________/__________________________________ Number of Years_____________

Business Contact Information:

Home Contact Information:

_________________________________________

___________________________________________

Street

_________________________________________

___________________________________________

City, State, Zip

___________________ /_____________________

____________________ /_______________________

Business Phone

Business Email

Home Phone

Home Email

You may contact me at work

____________________/________________________

YES____________

NO_________

Work Cell Phone

Personal Cell Phone

Highest Earned Degree Held ___________ Have You Ever Been Convicted of a Felony

Yes______ No______

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Drivers License Number___________________________________State___________If non U.S., Issuing Authority________________________

Social Security Number _______________________________ US Citizen? YES_____ NO____

Date of Birth _______/_______/_______

(The items above are not considered in the selection process----Only used in background checks)

References

List a minimum of 4 references beginning with your current immediate supervisor or if you report directly to a Board, to the Board Chair.

Additional references may be attached.

PLEASE DO NOT INCLUDE REFERENCES IN YOUR LETTER OF INTEREST OR RESUME.

Name and Position

Business Phone

Home Phone

I give permission for the consultants working with the Board of Trustees of Carteret Community College in its President Search to contact

anyone listed on this data sheet or any other individuals who are likely to have information that would help in ascertaining my potential for

success as the President of CCC. I understand I need not be notified nor give any further permission for the reference checks to be conducted.

I understand I will not be given the names of the references checked during this search nor do I have any rights to the results of those checks

and reports given to the Board or any entity of the Board either verbally or in writing or any notes or records kept during the reference check

process. I further understand that any application materials submitted to the Board of Trustees of CCC will not be returned to me. I also give

my permission for the consultants or their agents to conduct a criminal background check, a credit check, and an employment check on me. If I

had questions or concerns regarding this information and the permission I am granting, I contacted Dr. Donny Hunter and those questions and

concerns were either resolved or they are noted on the reverse side of this document. My signature below verifies that all information on this

sheet, in the résumé I submit, in my signed letter of interest, and in any additional information I might be asked to submit is true, accurate, and

complete. I understand that the submittal of untrue, inaccurate, or incomplete information will eliminate me from consideration as an applicant

and, if discovered after the fact, will be grounds for dismissal should I be employed as President of Carteret Community College.

Applicant's Signature: _________________________________________________________ Date: _______________________

Inforamtion Reference Sheet - Carteret Community College

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