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Clark County School District #161

NON-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:                                                                                                                  

 

                                                   EDUCATION                                                 

Starting with first high school, list in order of attendance, all institutions

 

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 employment for the past

15 years. 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:

 

 

 

Employer:

 

Address:

 

 

Job Title:

 

Employed from             to

 

Salary:

 

 

Specific Duties:

 

 

Immediate Supervisor: _

 

Phone:

 

 

Reason for Leaving:

 

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 lessor 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                                                                                                                                                                 

 

REFERENCES

 

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

information about your work skills.

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby authorize 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