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Date___________________________
PERSONAL
Name_________________________________
SS#________________________
Present
Address_____________________________________________________
Permanent
Address___________________________________________________
Home
Phone#____________________ Work Phone#________________________
Have
you ever been convicted of a felony?________If so,
w_____________________
EMPLOYMENT
DESIRED: ______________________________________________________
List
any special skills you possess: (Example: Professional or
institutional food preparation or handling, baking, etc.)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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EDUCATION: |
Name
of School |
#
Years Attended |
Graduated
Yes \ No |
Major
Field |
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High
School |
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College
or University |
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College
or University |
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AVAILABILITY
Date
you can start______________ Are you employed
now?____________________
If
so, may we inquire of your present
employer?_______________________________
May
we contact other references prior to an
interview?_________________________
FORMER
EMPLOYERS: Please list below your last four employers
(most recent one first).
|
Month/Year |
Name/Address
of Employer |
Home
Phone |
Work
Phone |
Position
Held |
Reason
for Leaving |
|
From
To |
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From
To |
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From
To |
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From
To |
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REFERENCES:
Give below the names of three persons not related to you whom you
have known at least one year (preferably
in the teaching profession).
|
Name |
Address |
Phone
# |
Occupation |
Years
Acquainted |
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CERTIFICATION:
I hereby certify that the information given by me in this
application is true, correct and complete; and I hereby authorize
personnel in the district to examine my records and contact any of
my schools, former employers or other references for the purposes of
collecting information regarding my employment, education,
experience and fitness as an employee. I authorize such references
to disclose information regarding my employment, education,
experience and fitness as an employee, and I agree to hold any and
all of such references harmless and free of any liability for
releasing any truthful information about me.
I understand that if I am employed, any false or misleading
statement made or implied on this application, any omission herefrom,
or any inconsistency between the information I have provided herein
and information obtained from any criminal history records check,
Statewide Sex Offender Database check, Statewide Child Murderer and
Violent Offender Against Youth Database check, or background
investigation is sufficient cause for dismissal.
_____________________________________
__________________________
Signature
Date
APPLICATIONS
REMAIN ACTIVE FOR ONE YEAR-REAPPLICATION IS NECESSARY
AFTER THAT
TIME
Do
not write below this line
Date
of Interview____________ Time________ Interviewed
by:__________________
Remarks____________________________________________________________
___________________________________________________________________
___________________________________________________________________
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