Louisiana School for Math, Science, and the Arts - Application for Employment

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1 Louisiana School for Math, Science, and the Arts - Application for Employment The Louisiana School for Math, Science, and the Arts does not discriminate in employing persons on the basis of race, creed, religion, color, national origin, gender, marital status, age, disability, or veteran status. General Information (Please type or print) Name Other Names Ever Used Mailing Address Daytime Telephone Number Evening Telephone Number Address Position Sought Background Information 1. YES NO Do you possess a valid driver s license? 2. YES NO Are you currently holding or running for an elective public office? 3. YES NO Have you ever been on probation or sentenced to jail as a result of being convicted, or pled guilty to a felony? If you answered YES to Question 3, list below the law enforcement authority involved (city police, sheriff, FBI, etc.), the offense, the date of the offense, and the place and disposition of each case.

2 Louisiana School for Math, Science, and the Arts - Application for Employment - Page 2 4. YES NO Have you ever been fired from a job or resigned to avoid dismissal? If you answered YES to Question 4, please explain. 5. YES NO NA If you are applying for a position that involves the handling of cash or other funds or financial information for the School or students, are your wages currently being garnished? 6. YES NO NA If you are a male between the ages of 18 and 25, are you registered with the Selective Service System or are you exempted from such registration? CONSENT AND RELEASE Please Read Each Statement Carefully Before Signing I certify that all information provided in this employment application and all supplemental material is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. If such current or prior employer is a city, parish or other local public school board, I authorize the disclosure by such employer s information of all instances of sexual misconduct with students as committed by me, if any. I release such persons and organizations from any legal liability in making such statements including the providing of any information involving sexual misconduct with students. I understand, if a successful applicant, I will be required to submit to and pass a drug screening examination and a criminal background check that includes fingerprinting. I hereby consent to the drug screen and the criminal background check as a condition of employment. If employed, I understand that annually I will be required to submit a financial disclosure statement and a dual employment statement. If my position might involve or require transporting students, driving school-owned vehicles, or driving a personal vehicle for school-related business, I must complete a state-sponsored driving examination (written test) every three years. I understand that if I am extended an offer of employment it may be conditioned upon successfully passing a complete physical examination. I consent to the release of any and all medical information as may be necessary to judge my capability to the work for which I am applying.

3 Louisiana School for Math, Science, and the Arts - Application for Employment - Page 3 I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR PROVIDE FOR EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. I have read, understand, and by my signature consent and agree to these statements. Signature: Date A professional resume may be substituted for the Employment History and Education History required below. Employment History List all jobs and activities, including military service, full-time employment, part-time employment, self-employment, and volunteer work. Begin with your MOST RECENT or CURRENT job and end with your FIRST job. A Employer/Company Name Name, Title, and of your supervisor and a person who can verify this employment:

4 Louisiana School for Math, Science, and the Arts - Application for Employment - Page 4 B Employer/Company Name Name, Title, and of your supervisor and a person who can verify this employment: C Employer/Company Name Name, Title, and of your supervisor and a person who can verify this employment:

5 Louisiana School for Math, Science, and the Arts - Application for Employment - Page 5 D Employer/Company Name Name, Title, and of your supervisor and a person who can verify this employment: E Employer/Company Name Name, Title, and of your supervisor and a person who can verify this employment:

6 Louisiana School for Math, Science, and the Arts - Application for Employment - Page 6 Educational History A. List Business, Vocational, or Technical colleges or schools attended Dates Attended (Month/Year) Graduate? Program Sem. School Name/Location FROM TO YES NO Title Hrs. B. List Colleges and/or Universities Attended Dates Attended Degree Field Date of (Month/Year) Earned of Graduation Institution Name/Location FROM TO (BA, MS, etc) Study (Month/Year) / / / / C. List Major Subjects Sem. Hrs. Sem. Hrs. Major Undergraduate Subjects Earned Major Graduate Subjects Earned D. List Professional Licenses and Certifications Date of Expiration Type of License/Certificate Issue Date Name/Address of Issuing Agency Attach names and contact information for at least three references.

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