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1 JOHNSTON PUBLIC SCHOOLS 10 Memorial Avenue Johnston, Rhode Island Phone: / Fax: FULL TIME PART TIME SUBSTITUTE APPLICAT ION FO R EM PLOYM ENT C ER TI FIED TEACHER / A D MI NISTRATOR DATE OF APPLICATION: POSITION APPLYING FOR: NAME: LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NUMBER(S): ADDRESS: EMERGENCY CONTACT: RELATIONSHIP: EMERGENCY CONTACT PHONE NUMBER(S): Dear Applicant: Thank you for your interest in working for the Johnston Public Schools. Your application packet will be considered complete when we have received ALL of the following documents: For Office Use Only Letter of Interest... Completed Application... Résumé... 3 Current Letters of Reference... Copy of Rhode Island Teaching Certificate... Student or Official Issued College Transcripts... Copy of Praxis / Principles of Learning and Teaching (PLT) Scores... Equal Employment Opportunity (EEO) Form... TB Test Results (No older than 6 months)... National Criminal Background Check (BCI) (No older than 1 year)... W-4 Form... Direct Deposit Form... I-9 Form... 2 Forms of Identification or Passport (see last page)... JOHNSTON PUBLIC SCHOOLS EMPLOYMENT APPLICATION CERTIFIED TEACHER / ADMINISTRATOR Rev. (01/2014)

2 1. PERSO NAL I NFORM AT ION (Please type or print plainly) Are you a retired teacher? Yes No If yes, from what state did you retire? Have you ever been employed by the Town of Johnston? Yes No If Yes, in what capacity and time frame? Applications will be kept on file for one school year. 1. Are you a US Citizen or legal resident of the United States? Yes No 2. Are you a member of the Employees Retirement System of Rhode Island? Yes No 3. Have you ever been dismissed from or asked to leave a position of employment? Yes No 4. Have you ever had a teaching certificate or license revoked for cause? Yes No If you answered Yes to question 3 and/or 4, please explain: 2. EDUCATIO N Name & Address of School Course of Study Years Completed Diploma/Degree Earned High School Undergraduate Graduate/Professional Other (specify) 3. TEACHING EXPERI ENCE Start with most current experience. Name & Address of School Dates Employed Subject or Grade Taught Last Salary Reason for Leaving Have you been considered tenured in any of your previous/present teaching position(s)? If Yes, please specify in which school district(s) and the dates of employment. Yes No 4. OTHER EM PLOYM ENT Start with most current experience. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. Include any job-related military service assignments and volunteer activities. Name & Address of Employer Dates Employed Position Last Salary Reason for Leaving If currently employed, may we contact your present employer? Yes No JOHNSTON PUBLIC SCHOOLS EMPLOYMENT APPLICATION CERTIFIED TEACHER / ADMINISTRATOR Rev. (01/2014)

3 5. CERTIF ICATIO N( S) Certification Number Certification Area State of Issue Expiration Date Are you Highly Qualified? (Praxis) Yes No 6. REF ERENCES Please give as references persons who have personal experience and knowledge regarding your character, personality, teaching and administrative abilities, in a public school. If you are experienced in teaching or administration, please include the names and addresses of superintendents, principals, or supervisors with whom you have served. Please note that the persons named as references will be contacted during this process. If you prefer that any one of your references not be contacted until you have achieved finalist status, please indicate such request in writing. Name / Title Address Telephone Number AFFIRMATION I certify that the information provided in this job application is true and complete to the best of my knowledge and there are no willful misrepresentations or falsifications of any statements. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I agree to execute such form(s) as the Johnston Public Schools may require enabling the Johnston Public Schools to investigate my performance in my current and previous job. I understand and agree nothing contained in this application shall be deemed an employment contract between the Johnston Public Schools and myself for either employment or providing any benefit. I further understand and agree that the granting of an interview shall likewise not create such a contract. No promises regarding employment or inducements to take employment have been made or offered to me and I understand and agree that no such promises are binding upon the Johnston Public Schools unless made in writing. I understand that should an investigation disclose such misrepresentations and falsifications, my application may be rejected. In the event of my employment, I understand that any false or misleading information given in this application or which I have provided by way of a résumé or during interview(s) may result in discharge. I understand, also, that the collective bargaining agreement(s) governing bargaining units may apply to me. CONDITION OF EMPLOYMENT As a condition of my employment, I also agree to abide by any/all Rules, Regulations and/or Policies set forth by the Johnston Public Schools. Policies include but are not limited to the Code of Ethics, Code of Conduct, Sexual Harassment, No Smoking Policy, and others as they may now be in effect or any future Rules, Regulations and/or Policies and/or additions to existing Rules, Regulations and/or Policies as the Johnston Public Schools deems necessary. Applicant Name PRINTED: Applicant Signature: Date: The Johnston Public Schools welcomes diversity in its employment opportunities, programs, and activities. It is the policy of the Johnston Public Schools not to discriminate on the basis of age, sex, marital status, race, religion, national origin, color, political affiliation, or handicap in its employment practices. Inquiries regarding compliance with Equal Opportunity/Affirmative Action may be directed to: Johnston Public Schools Administration Office, 10 Memorial Avenue, Johnston Rhode Island 02919, ATTN: Equal Opportunity/Affirmative Action Officer The Johnston Public Schools is subject to the provisions of the Workers Compensation Act. JOHNSTON PUBLIC SCHOOLS EMPLOYMENT APPLICATION CERTIFIED TEACHER / ADMINISTRATOR Rev. (01/2014)

4 EEO: EEO-1 Voluntary Self Identification Form The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO-1 report each year. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources Department. NAME: JOB TITLE: GENDER: (Please check ) Male Female RACE/ETHNICITY: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.) Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above five races. DATE COMPLETED: Thank you for your participation. JOHNSTON PUBLIC SCHOOLS EMPLOYMENT APPLICATION CERTIFIED TEACHER / ADMINISTRATOR Rev. (01/2014)

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7 JOHNSTON PUBLIC SCHOOLS 10 Memorial Avenue Johnston, Rhode Island Phone: / Fax: Johnston Police Department 1651 Atwood Avenue Johnston, RI ATTN: BCI Department CONDITIONAL LETTER OF INTENT TO HIRE As part of our employment application requirement, the holder of this letter is seeking employment with the Johnston Public Schools and is in need of a National and State Criminal Background Check in accordance with the Rhode Island General Laws 1. 1 National and State Criminal Background Check Rhode Island General Laws Criminal records review., Prior criminal records checks. (a) Any person seeking employment with a private school or public school department who has not previously been employed by a private school or public school department in Rhode Island during the past twelve (12) months shall undergo a national and state criminal background check. JOHNSTON PUBLIC SCHOOLS EMPLOYMENT APPLICATION CERTIFIED TEACHER / ADMINISTRATOR Rev. (01/2014)

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10 Johnston Public Schools Payroll Direct Deposit Authorization EMPLOYEE NAME (PLEASE PRINT): DATE OF BIRTH: Direct Deposit Request & Authorization From my net pay each pay period, I hereby authorize and request you to: Bank Name Router # Acct. # Chk. Sav. Bi-weekly Amount $ $ $ If you would like the entire balance of your net pay to be deposited, please indicate BALANCE in the Amount column. NOTE: This form will replace any previously submitted Direct Deposit authorization forms; therefore, must be completed in its entirety including ALL (present and additional) bank names, router numbers, account numbers and amounts. If possible, PLEASE ATTACH A VOIDED CHECK for each account listed to this request. This authorization may be cancelled at any time by written notification to the company. Any such notification shall be effective only after the company has had reasonable time to act upon it. EMPLOYEE SIGNATURE: DATE: FOR OFFICE USE: PAYROLL SIGNATURE: DATE ENTERED: JOHNSTON PUBLIC SCHOOLS EMPLOYMENT APPLICATION CERTIFIED TEACHER / ADMINISTRATOR Rev. (01/2014)

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