NORWOOD-NORFOLK CENTRAL DISTRICT NORWOOD, NEW YORK (315) APPLICATION FOR EMPLOYMENT PROFESSIONAL PERSONNEL

Transcription

1 NORWOOD-NORFOLK CENTRAL DISTRICT NORWOOD, NEW YORK (315) APPLICATION FOR EMPLOYMENT PROFESSIONAL PERSONNEL NAME First Middle Last ADDRESS CITY & STATE ZIP CODE POSITION OF (Indicate Teacher, Counselor, Administrator, Librarian, etc.) Please check appropriate categories: Elementary Secondary Middle School Subject(s) Substitute The Norwood-Norfolk Central School District is an Equal Opportunity and an Affirmative Action Employer according to Civil Rights Legislation and Title IX. Contact Title IX Compliance Officer in the District in case of questions. For Office Use Only (11/12) Application Received:

2 Name First Middle Last Telephone: ( ) Social Security Number Are you a citizen of the United States: Are you a member of the New York State Teachers Retirement System? If yes, indicate retirement number and tier: Number Tier Do you have New York State Education Department Fingerprint Clearance? Yes No Were you ever in the Military? Yes No If yes: Branch Dates Discharge received Rank Have you ever been convicted of a crime, excluding misdemeanors and summary offences? Yes No If yes, explain: Certification Information: Certification Area: Types of New York State Certification: Certificate of Qualification Number & Expiration Date Provisional Certificate Number & Expiration Date Initial Certificate Number & Expiration Date Professional Certificate Number &Expiration Date None Are you certified in another state? If yes, State Type of Certification Number If uncertified, when do you expect to obtain certification? In what area? On what date would you be available to begin? Personal interests and hobbies: Special abilities. Indicate any extracurricular activities and/or sports you would be able to teach or coach: Other qualifications: Summarize special job-related skills and qualifications acquired from employment or other experiences:

3 EDUCATIONAL BACKGROUND: High School: Course of Study Years Attended Diploma Undergraduate School: Course of Study Years Attended Diploma Graduate School: Course of Study Years Attended Diploma Other (specify) *********************************************************************** WORK EXPERIENCE: (May we contact your present employer? Yes No )

4 REFERENCES: What do you consider the most important qualities, talents, or characteristics which you have to bring to this position? Please present your thoughts briefly. I attest to the fact that all information in this application is true and accurate. I grant my permission to the Norwood-Norfolk Central School District to contact former and current employers, law enforcement agencies, educational institutions, licensing/certifying agencies, and personal references. I authorize any and all of the above individuals and agencies to provide Norwood-Norfolk Central School District with the information requested, as long as the information given is relevant to the job duties/responsibilities for which I have applied, and hereby release from liability any such individual or agency contacted by the Norwood-Norfolk Central School District in connection with my application. Signature Date

5 NORWOOD-NORFOLK CENTRAL SCHOOL 7852 State Hwy. 56, Norwood, New York (315) This facility is an equal opportunity employer. We recruit, hire, train and promote without discrimination due to race, color, creed, six, national origin, ancestry, marital status, age, sexual orientation. PRE-EMPLOYMENT INQUIRY RELEASE In connection with my application for employment (including contract for services), with you, I understand that investigative background inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various federal, state and other agencies, which maintain records concerning my past activities relating to my driving, credit, criminal, civil and other experiences as well as claims involving me in the files of insurance companies. *NOTE: Fingerprinting and clearance from SED is required as a condition of employment. I authorize, without reservation, any party or agency contacted by the employer to furnish the above-mentioned information. PRINT FULL NAME: Last First Middle Maiden Other name(s) you have worked/schooled under: SOCIAL SECURITY NUMBER - - *DATE OF BIRTH / / (Not Required) CURRENT ADDRESS: CITY/STATE/ZIP CODE: COUNTY: DRIVER S LICENSE NUMBER: STATE: *Date of Birth is being requested in order to obtain accurate retrieval of records. As the authorizing party, I hereby agree to release to Norwood-Norfolk Central School, Norwood, New York, and all concerned from and against any and all claims, demands, actions, suits and proceedings by others including but not limited to any liability for damages in connection with any information received and used concerning my employment. I further understand that any offer of employment is based upon the completion of a background investigation. AUTHORIAZING PARTY S SIGNATURE: Notary Public: Sworn to before me on this day of,.