|
Applicant Information |
Last Name: |
First Name: |
M.I. |
|
Street Address: |
Apt: |
City: |
State: |
Zip: |
Phone: |
|
Email: |
Date of birth: |
SSN: |
|
Position Desired: |
Date Available: | |
Are you a US citizen? Yes No |
If no, are you a legal alien? Yes No |
Have you ever been convicted of a crime? Yes No |
If yes, please explain: |
Do you have any physical impairment that would interfere with your performance in the position for which you are applying?
Yes No |
|
Emergency contact: |
Phone: |
Relationship: |
|
References |
|
Name: |
Relationship: | Company: |
|
Phone: | |
| |
|
Name: |
Relationship: | Company: |
|
Phone: | | |
| |
|
Name: |
Relationship: | Company: |
|
Phone: | |
| |
|
Name: |
Relationship: | Company: |
|
Phone: | |
|
Education and Professional Training |
|
High School: |
City and State: |
Dates Attended: |
|
Graduation Date: |
|
College or University: |
City and State: |
Dates Attended: |
|
Graduation Date: |
Degree: |
Total Semester Hours: |
|
Graduate School: |
City and State: |
Dates Attended: |
|
Graduation Date: |
Degree: |
Total Semester Hours: |
|
Other education, training or comments: |
|
College Activities: |
Hobbys, special interests: |
|
Non-Teaching Experience |
Company: |
Phone: |
Address: |
|
Supervisor: |
Title: |
Starting/Ending Salary: |
|
Start Date: |
End Date: |
Reason for leaving: |
|
Responsibilities: |
May we contact this employer for a reference? Yes No |
| |
Company: |
Phone: |
Address: |
|
Supervisor: |
Title: |
Starting/Ending Salary: |
|
Start Date: |
End Date: |
Reason for leaving: |
|
Responsibilities: |
May we contact this employer for a reference? Yes No |
| |
Company: |
Phone: |
Address: |
|
Supervisor: |
Title: |
Starting/Ending Salary: |
|
Start Date: |
End Date: |
Reason for leaving: |
|
Responsibilities: |
May we contact this employer for a reference? Yes No |
| Military Service |
|
Branch: |
From: |
To: |
Rank at discharge: |
|
Type of discharge: |
|
Agreement |
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal without notice at any time during my employment.
I agree, if employed to follow all rules and regulations of the district.
I understand by state law the board of education must require all employees to submit to health certificates from their physician along with a chest X-Ray report or tuberculin test yearly. I further understand and agree to promptly notifiy the district of any change of address during my employment. Agree Disagree Date: |