Application For Employment Unified School District of De Pere

.

1700 Chicago Street * De Pere, WI 54115 Phone: (920) 337-1032

Position Applying for:-------------------------------Available: __ Part Time* Full Time Date Available: ___/ ___/ __ *If Part Time, specify hours & days available

Personal Data 1. Name=-----------..,,..--------...,.,,.....------ Social Security#:---~___] ___ _ ~ - ~ 2. PresentAddress=----------------------------------=-----av State 3. Home Telephone: ( __ ) __ -___ _ Work Telephone: ( __ ) __ -__ _

4. Have you worked for the Unified School District of De Pere before? ___ If yes, when and in what capacity? _____ _

5. Can you perform, with or without accommodation, the duties of the position you seek? with accommodation without accommodation

If accommodation is needed, briefly describe what is needed:

6. Have you ever been found guilty of or do you presently have pending any violations of law (felonies and/or misdemeanors) other than minor traffic violations? (in accordance with State law pending charges or convictions will not be considered unless substantially related to circumstances of the particular job) No Yes If yes, please attach a complete written explanation.

7. Have you ever been dismissed or asked to resign from any employment or other position? Yes No If yes, please explain and attach further explanation as is necessary---------------------

8. Education And Training Circle the highest grade or year completed in school: Name & Location of High School

6 7 8 9 10 11 12 13 14+

Training Beyond High School (College or University, Nursing, Business, Tech/Voe. Etc.) Dates Credits Major Field Degree Conferred & YEAR

Name of Institution Attended Earned and Address From To

....

9. Describe any education or training you have had which is not covered above, such as on the job, correspondence courses, service schools, in-service training, which you feel is relevant to the job for which you are applying. Also include relevant licenses or certificates. (Be Specific)

10. EMPLOYMENT Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer. Name Of Employer

Telephone

Address Employed (State Month & Year) From To

1 Name of Supervisor Weekly Pay Start Last State Job Title & Describe Your Work Reason for Leaving

Name Of Employer Telephone

Address Employed (State Month & Year) From To

2 Name of Supervisor Weekly Pay Start Last State Job Title & Describe Your Work Reason for Leaving

Name Of Employer Telephone

Address Employed (State Month & Year) From To

3 Name of Supervisor Weekly Pay Start Last State Job Title & Describe Your Work Reason for Leaving

Name Of Employer Telephone

Address Employed (State Month & Year) From To

4 Name of Supervisor Weekly Pay Start Last State Job Title & Describe Your Work Reason for Leaving

Name Of Employer Telephone

Address Employed (State Month & Year) From To

5 Name of Supervisor Weekly Pay Start Last State Job Title & Describe Your Work Reason for Leaving

Additional employment data may be attached on a separate sheet. Please include all pertinent information.

DO NOT CONTACT EMPLOYER NUMBER(S) 11. We may contact the employers listed unless you indicate those you do not want us to contact. Reason_~-----------------~----------------

12. Freedom from non-prescribed controlled substances is a condition of employment in the De Pere School District. Periodic tests may be utilized to verify this status. Are you free from non-prescribed controlled substances? Yes No

13. Explain any additional experiences, talents or skills that you possess which would be applicable to the position for which you are applying.

VERIFICATION/AUTHORIZATION I authorize the Unified School District of De Pere (USDDP), in De Pere, Wisconsin, to make any inquiry of or receive any information from any person or organization regarding my suitability for employment, and do hereby expressly give permission to these persons or organizations to provide such information. Such inquires may include, but are not limited to, the verification of any information set forth in this application, the quality and quantity of my work, my work history and medical records, and my character, qualifications, and background. In consideration for the cooperation extended to USDDP by release of such information, I forever waive, release, and covenant not to sue any person or organization, including USDDP and its agents and employees, for providing, obtaining, verifying, or otherwise acting upon such information. I give this waiver, release, and covenant not to sue for myself, my heirs, assigns and successors in interest forever. I do so understanding that the information obtained may be such as to disqualify me for employment, or result in rejection of my application or my dismissal from employment. I understand that such information is sought with confidentiality, and I will not request copies thereof. I certify that all information provided herein is accurate to the best of my knowledge, information and belief, and I acknowledge that any false statements, incomplete statements, or misrepresentations may subject me to disqualification, rejection, or dismissal at any time. A copy of this authorization shall be as effective as the original for the purposes stated above. I HAVE READ AND UNDERSTAND THE FOREGOING CERTIFICATION, AND SIGN BELOW VOLUNTARILY AND WITH KNOWLEDGE OF ITS CO'ITENTS.

Signature Date

(Note: This application is subject to consideration by the Unified School District of De Pere for a period of ninety (90) days.)

The Unified School District of De Pere is an equal opportunity employer and adheres to all applicable Federal and State laws prohibiting discrimination in employment.