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Clark County School District #161

CERTIFIED APPLICATION FOR EMPLOYMENT

 

P.O. Box 237, Dubois, ID 83423

 

 

Clark County School District #161 is an equal opportunity employer that encourages applications from all persons regardless of race, religion, sex, age, national origin, or disability.

 

 

Position applying for:                                                                 

 

Date of application:                                      

 

 

 

Name:                                                                                        

 

Social Security Number:                               

 

 

Present Address:                                                                                                                                                        

 

Permanent Address:                                                                                                                                                  

 

Telephone:                                                                                                                                                                   Home                                      Work                                       Message

Present Position or Employment Status:                                                                                                                  

 

Idaho Certification:                                                                                                                                                Number         Title                                         Endorsements

 

                                                   EDUCATION                                                 

Starting with last high school, list in order of attendance, all institution

 

Name of Institution

City and State

Dates Attended Mo/Yr to Mo/Yr

Credits Earned

Sem or Qtr

Degree

Earned

Degree Date

Major

Minor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYMENT HISTORY

 

List your current employer first and continue in reverse chronological order.  List all previous employment.

Use extra copies of page 2 as necessary. May we contact your current employer?                                       

Employer:                                                                                                                                                                  

 

Address:                                                                                                                                                                    

 

 

Job Title:                                                               

 

Employed from          

 

to             Salary:                              

 

 

Specific Duties:                                                                                                                                                        

 

 

Immediate Supervisor: _                                                             

 

Phone:                                

 

 

Reason for Leaving:                                                                                                                                                  

 

 

 

Employer:

 

Address:

 

 

Job Title:

 

Employed from             to

 

Salary:

 

 

Specific Duties:

 

 

Immediate Supervisor: _

 

Phone:

 

 

Reason for Leaving:

 

 

 

Employer:

 

Address:

 

 

Job Title:

 

Employed from             to

 

Salary:

 

 

Specific Duties:

 

 

Immediate Supervisor: _

 

Phone:

 

 

Reason for Leaving:

 

 

 

Employer:

 

Address:

 

 

Job Title:

 

Employed from             to

 

Salary:

 

 

Specific Duties:

 

 

Immediate Supervisor: _

 

Phone:

 

 

Reason for Leaving:

STUDENT TEACHING

 

If you have under four years of full time teaching experience please list your student teaching experience.

 

 

School:                                                        

 

Address:                                                  

 

Dates:                            

 

 

 

Supervising Teacher:                                                   

 

Phone #                                          

 

 

 

College Supervisor :                                                   

 

Phone #                                          

 

 

 

 

REFERENCES

 

Please list people other that immediate supervisors indicated in employment history who can provide

information about  your professional work skills.

 

Name and Position            Institution/Name of Firm          Address, City, State           Business Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER INFORMATION

Have you ever been convicted of, pled guilty or nolo contendre to, or been granted deferred adjudication for a felony, misdemeanor, (excluding juvenile adjudication), or any lesser crime other

than a minor traffic infraction? .................................................................................................................  ¨ Yes  ¨ No

If yes, list all such offenses and provide date, name of court, and disposition.  Omission of information may be considered cause for disqualification from the employment pre-screening process or result in termination of employment.

 

 

 

 

Have you ever been disciplined in your employment related to workplace violence? ..............................   ¨ Yes  ¨ No If yes, please explain.

 

 

 

Do you presently use illegal drugs? ...........................................................................................................   ¨ Yes  ¨ No

 

Have you ever been employed by Clark County School District #161?....................................................   ¨ Yes  ¨ No If yes, please provide the following information:

Department                                                             Position                                                                                    Title                         Dates of Employment                       Reason                                          for                                          Separation                     Are you related to anyone who is currently employed by Clark County School District #161? ...............   ¨ Yes  ¨ No

If yes, please provide the following information:

 

Related person's name                                                          Department                                                                         Relationship                                                                                                                                                                  

I hereby authorize the Clark County School District #161 to inquire from any former and current employer (if indicated on page 2), references, credit bureaus, and law enforcement agencies regarding my background, employment, performance, and to confirm the accuracy of the information I have provided in this application.  I understand that misrepresentation or omission of information requested is cause for dismissal, and I affirm that the information provided in this application is complete and accurate.

 

 

Signature                                                                                             Date