Online Employee Application

Thank you for choosing to disclose your status as a person with a disability to the university. Please complete the following application and submit supporting documentation. You will then be contacted concerning next steps.

Personal Information

First Name *:
Last Name *:
Middle Name:
Optional: Preferred Name:
Employee ID *:
Hint: Enter 9 alpha numeric characters.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender *:

Contact Information

Cell Phone Number *:
Hint: Enter 10-digit number only.
Land Line Phone Number:
Hint: Enter 10-digit number only.
MTSU Email *:

Local Address

Address *:
City *:
State *:
Zipcode *:
Hint: Enter zipcode as 97331 or 97331-0000.

Permanent Address Same as Local Address

Address:
City:
State:
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.

Questions

Position Title
Office Location
If you have a mobility or other impairment that may make evacuation during an emergency difficult, would you be interested in the Director of ADA Compliance informing emergency management personnel of your office location in case of an emergency? * (Selection is Required)

Yes

No

Not Applicable

Additional Note or Comment
Are you interested in discussing workplace accommodation? * (Selection is Required)

Yes: Please describe how your diagnosis manifests, the way the manifestation impacts your ability to perform your job duties, and what accommodation you think could alleviate the impact (Specify Below)

No

Unsure

Additional Note or Comment

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Office of Institutional Equity and Compliance