Cheverus High School APPLICATION FOR EMPLOYMENT

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1 Cheverus High School APPLICATION FOR EMPLOYMENT CHEVERUS HIGH SCHOOL IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER. Applications are considered for all positions without illegal regard to age, race, color, sex, national origin, handicap, medical condition, veteran or marital status. 267 Ocean Avenue, Portland, Maine (Tel.) (Fax)

2 PERSONAL NAME (PLEASE PRINT OR TYPE) LAST NAME, FIRST NAME, MIDDLE NAME MAIDEN / OTHER NAMES USED IN THE PAST SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER / STATE CURRENT ADDRESS STREET NUMBER & NAME, CITY, STATE AND ZIP CODE PREVIOUS ADDRESS STREET NUMBER & NAME, CITY, STATE AND ZIP CODE PHONE NUMBER TO CONTACT: (please indicate best number to contact.) HOME: CELL: NOTIFY IN CASE OF EMERGENCY: NAME: ADDRESS: HAVE YOU EVER BEEN EMPLOYED BY CHEVERUS HIGH SCHOOL? NO YES IF SO, WHEN? CITZENSHIP: US CITIZEN / PERMANENT RESIDENT NON-IMMIGRANT VISA: B1 F1 J1 L1 H1 OTHER HAVE YOU EVER BEEN CONVICTED OF A FELONY? NO IF YES, PLEASE EXPLAIN IN COMMENTS SECTION. YES ARE YOU AT LEAST 18 YEARS OF AGE? NO YES EMERGENCY CONTACT PHONE:: HOME: CELL: WORK: DO YOU HAVE ANY RELATIVES CURRENTLY EMPLOYED AT CHEVERUS HIGH SCHOOL? NO YES IF SO, WHO? RELATIONSHIP: HAVE YOU ANY MENTAL OR PHYSICAL CONDITIONS / DISABILITIES WHICH WOULD LIMIT YOU IN PERFORMING SPECIFIC KIND OF JOB FUNCTIONS? NO YES IF YES, WHAT ACCOMODATIONS CAN BE MADE? PLEASE EXPLAIN IN THE COMMENTS SECTION. HAVE YOU EVER BEEN CONVICTED OR ACCUSED OF A SEXUAL ASSAULT OF ANY TYPE? NO YES IF YES, PLEASE EXPLAIN IN COMMENTS SECTION. POSITION DESIRED TYPE OF POSITION DESIRED: FIRST CHOICE DATE AVAILABLE / / SALARY DESIRED $ SECOND CHOICE TYPE OF EMPLOYMENT DESIRED: FULL TIME PART TIME TEMPORARY WHAT PROMPTED YOUR APPLICATION? ADVERTISEMENT please give source: EMPLOYEE REFERRAL please give name: AGENCY please list name and location: COLLEGE REFERRAL please list name and location: WALK IN

3 EDUCATION AND TRAINING INDICATE LAST LEVEL OF EDUCATION COMPLETED HIGH SCHOOL COLLEGE DEGREES SUBJECT TO VERIFICATION COLLEGE OR UNIVERSITY _ GRAD SCHOOL COLLEGE OR TRADE SCHOOL (DO NOT ABBREVIATE) LOCATION (CITY & STATE) PROVINCE COUNTRY DATES ATTENDED MAJOR/MINOR DATE/DEGR EE AWARDED HONORS ADDITIONAL EDUCATION, VOCATIONAL AND/OR PROFESSIONAL INFORMATION: CLERICAL SKILLS (IF APPLICABLE) TYPING WPM SHORTHAND WPM TEN-KEY OTHER OFFICE OR PRODUCTION MACHINES REQUIRING SPECIAL SKILLS (please list) EMPLOYMENT HISTORY - BEGIN WITH YOUR MOST RECENT POSITION. REGARDLESS OF ATTACHMENTS DO NOT USE "SEE RESUME" EMPLOYER (PLEASE LIST COMPLETE NAME) EMPLOYMENT DATES STARTING WAGE COMPLETE ADDRESS FROM TO $ JOB TITLE IMMEDIATE SUPERVISOR SHIFT ENDING WAGE DESCRIPTION OF DUTIES (USE "COMMENT" SECTION ON REVERSE IF ADDITIONAL SPACE IS NEEDED) $ REASON FOR LEAVING EXPLAIN UNEMPLOYMENT IF OVER THREE MONTHS

4 EMPLOYMENT HISTORY cont. EMPLOYER (PLEASE LIST COMPLETE NAME). EMPLOYMENT DATES STARTING WAGE COMPLETE ADDRESS FROM TO $ JOB TITLE IMMEDIATE SUPERVISOR SHIFT ENDING WAGE DESCRIPTION OF DUTIES (USE "COMMENT" SECTION ON REVERSE IF ADDITIONAL SPACE IS NEEDED) $ REASON FOR LEAVING EXPLAIN UNEMPLOYMENT IF OVER THREE MONTHS EMPLOYER (PLEASE LIST COMPLETE NAME). EMPLOYMENT DATES STARTING WAGE COMPLETE ADDRESS FROM TO $ JOB TITLE IMMEDIATE SUPERVISOR SHIFT ENDING WAGE DESCRIPTION OF DUTIES (USE "COMMENT" SECTION ON REVERSE IF ADDITIONAL SPACE IS NEEDED) $ REASON FOR LEAVING EXPLAIN UNEMPLOYMENT IF OVER THREE MONTHS EMPLOYER (PLEASE LIST COMPLETE NAME). EMPLOYMENT DATES STARTING WAGE COMPLETE ADDRESS FROM TO $ JOB TITLE IMMEDIATE SUPERVISOR SHIFT ENDING WAGE DESCRIPTION OF DUTIES (USE "COMMENT" SECTION ON REVERSE IF ADDITIONAL SPACE IS NEEDED) $ REASON FOR LEAVING EXPLAIN UNEMPLOYMENT IF OVER THREE MONTHS

5 EMPLOYMENT REFERENCES PLEASE LIST BUSINESS REFERENCES WE MAY CONTACT THAT ARE BEST QUALIFIED TO EVALUATE YOUR WORK EXPERIENCE. NAME YEARS KNOWN BUSINESS RELATIONSHIP BUSINESS ADDRESS / ORGANIZATION AREA CODE PHONE AGREEMENT THIS APPLICATION IS NOT COMPLETE UNTIL THE FOLLOWING STATEMENT HAS BEEN READ AND SIGNED: I certify that all the information furnished on this form is true, complete and correct to the best of my knowledge. I understand that such information is subject to verification. I understand that such information is subject to verification. I understand and agree that any material misrepresented or facts deliberately omitted inmy application may be justification for refusal of employment, or termination if employed. Either party may terminate employment at will. (ALL INFORMATION TREATED CONFIDENTIALLY) Signature of Applicant Date ADDITIONAL COMMENTS

6 Cheverus High School Athletic Department 267 Ocean Avenue, Portland, ME (207) Application for Coaching Position POSITION APPLIED FOR CANDIDATE S NAME Social Security Number Address City/State/Zip Telephone: Home Cell Work address EDUCATIONAL BACKGROUND High School Year of Graduation College Major Year of Graduation Graduate Work Year of Graduation EDUCATIONAL EXPERIENCE (Teaching) Check the following areas in which you have had formal training (i.e., course work or workshops): Coaching Techniques/Methods Sports Psychology First Aid Sports Science ACEP CPR Sports Medicine ACEP Sports Medicine Other (please specify) LIST PRIOR COACHING EXPERIENCE

7 List the names, addresses and telephone number of three people who know of your coaching experience: Name Address Phone # Name Address Phone # Name Address Phone # List athletic experiences relevant to this position or sport: Other pertinent information: If you are not employed by Cheverus, please provide the name of your employer, your immediate supervisor s name, telephone number, working hours and responsibilities: Cheverus believes that the modeling of good citizenship and values by adult leaders is very important to the process of educating student-athletes. Cheverus hopes to model, too the belief that the abuse of substances cannot be tolerated. In light of these tenets and cognizant of the nature of Jesuit Education, the applicant, by signing this application, attests that there are no experiences or beliefs which may act as a barrier to working at Cheverus and to the truthfulness of the statements made in this application. Applicant s Signature Date

8 AUTHORIZATION RELEASE OF CONFIDENTIAL SUBSTANTIATED MAINE CHILD ABUSE AND NEGLECT RECORDS INFORMATION Agency/Provider to receive this information: Agency ID#: 596 Michael S. Komich Cheverus High School 267 Ocean Avenue Portland, ME I,, authorize the Maine Department of Health and Human Services to release (Please print clearly) confidential information to the above agency regarding whether I have been involved in a substantiated Maine Child Protective Services case and the nature of that involvement. I understand that: o This release may be revoked by me in writing at any time, except for information that has already been released. For details contact Child Protective Intake at x2. o Disclosure will include the determination by the Department of any specific abuse/neglect to a child by me and any actions taken by me or the Department. o I may make a statement for the Department s record regarding the findings about me and any actions taken by me at that time or later to deal with the problems identified. Such statement becomes case record information for this or any other requests or authorizations for disclosure. For details, contact Child Protective Intake x2. o This information will be used as part of the above agency s assessment of my suitability to provide services for children, adults, and families they serve. o This information is subject to continuing confidentiality as provided by Maine statute, 22 M.R.S o This release will expire upon the disclosure of the information as authorized. o The fee for this process is $15.00 per person as authorized by 22 M.R.S. 4008(6) and DHHS Chapter 202 (2004), payable to Treasurer State of Maine. PLEASE DO NOT LEAVE ANY SPACES BLANK DATE OF BIRTH: ALIASES (including maiden): SIGNATURE: DATE: MAINE ADDRESS: RESULT BELOW (To be completed by DHHS): As of, this person was NOT INVOLVED in a substantiated Maine Child Protective Services case. DHHS, OCFS, Child Protective Intake Staff IF RESULT AREA IS BLANK, SEE REVERSE SIDE/ATTACHMENT

9 PT Research, Inc. HR Decision Support Services Consumer Report / Investigative Consumer Report Disclosure and Release of Information Authorization I authorize Cheverus High School and PT Research, Inc, a consumer-reporting agency, to retrieve information from all personnel, government agencies, companies, corporations, and law enforcement agencies at the federal, state or county level, relating to my past activities, to supply any and all information concerning my background, and release the same from any liability resulting from the preparation and reporting of such information. The information requested and disclosed on me will be limited to a public record Social Security Number trace, history of residence(s), and criminal conviction records. I understand that this information may be transmitted electronically and authorize such transmission. I understand that a Consumer Report may be prepared summarizing this information. I may request a copy of any report that is prepared regarding me and may also request the nature and substance of all information about me contained in the files of the consumer-reporting agency. I understand that I have the right to inspect those files with reasonable notice during regular business hours and that I may be accompanied by one other person. The consumer reporting agency is required to provide someone to explain the contents of my file. I understand that proper identification will be required and that I should direct my request to: PT Research Inc., P.O. Box 4540, Manchester NH Phone Attention: Compliance Officer. Are you applying for a VOLUNTEER position? YES NO I hereby certify that all the statements and answers set forth on the application form and/or my resume are true and complete to the best of my knowledge, and I understand that if subsequent to employment any such statements and/or answers are found false or that information has been omitted, such false statements or omissions will be just cause for the termination of my employment. Further, I understand that by requesting this information, no promise of employment is being made. I am willing that a photocopy of this authorization be accepted with the same authority as the original; and that if employed by the above named company, this authorization will remain in effect throughout such employment. Signature Social Security Number Date NOTE: The following information is provided voluntarily and IS NOT considered as part of your application. It is used only for identification purposes in verifying information on your Employment Application. PLEASE PRINT CLEARLY. Last Name First Name Middle Name Street Address City State ZIP Driver s License Number State of License Expires On Date of Birth* List any other CITIES AND STATES in which you have lived during the previous 7 years. List any other LAST NAMES you have used during the previous 7 years. List any other LAST NAMES under which you received your GED, high school diploma, or other degrees. *Providing your year of birth is strictly voluntary. This information will enable us to properly identify you in the event we find adverse information during the course of the background search. Revision 12/2007

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