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
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Name of Institution
City and State
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Dates Attended Mo/Yr to Mo/Yr
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Credits Earned
Sem or Qtr
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Degree
Earned
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Degree Date
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Major
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Minor
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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
