Non-Certifed Staff Application Form

Summit Public School District 54-6

PO Box 791

Summit, SD 57266

Phone: 398-6211 FAX: 398-6311

Name

Date

Address

City

State

Zip

Phone

Email Address

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Employment Desired

What position are you applying for? (please check)

Classroom Paraprofessional

(Teacher's Aide)

Bus Driver

Maintenance

Special Education Aide

Assistant Maintenance

Secretary

Food Service: (Must be able to lift up to 50 lbs. for these positions)

Food Service Director/Head Cook

Assistant Cook

Education and Training

High School Yrs. Completed

High School Diploma or Degree

Post-Secondary Yrs. Completed

Post-Secondary Diploma/Degree

Post-Secondary Grade Average

Post-Secondary Subjects Studied

Trade/Vocational Yrs. Completed

Trade/Vocational Diploma/Degree

Trade/Vocational Grade Average

Trade/Vocational Subjects Studied

Special Certifications/Licenses or Qualifications

List additional skills or training, knowledge, experience, or other relevant qualifications you consider applicable to obtaining position desired.

Do you type?

If yes, words per minute.

Please list computer programs you are trained in.

College or University name

Major

Minor

Degree

1.

2.

License No.

Year License Expires

Are you bi-lingual?

If yes, please list what language(s) other than English that you speak.

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Coaching/Extra-Curricular

Are you interested in any extra-curricular activities (i.e., coaching)?

If yes, breifly list your past extra-curricular or coaching experience.

Briefly list which extra-curricular activities or coaching activities you would be interested in.

Employment History

Employer Name

1.

2.

3.

Employer Address

Employer Phone

Supervisor Name

Supervisor Email

Date of Employment

Postition

Description of Duties

Why did you leave your last job?

References

Name

1.

2.

3.

Address--City, State, Zip

Phone

E-mail Adress

Years Acquainted

Criminal Background Information

Have you ever been charged with a misdemeanor or a felony?

If yes, explain the nature of the charge and the circumstances.

Were you convicted and/or did you plead guilty?

If yes, give the date, city, state, and county where convicted.

The School District will conduct a criminal background check on individuals upon making a contingent job offer.  No offer of employment shall become final until receipt of the results of the criminal background check, the content of which is acceptable to the School District, and approval by the School Board.

Certification, Acknowledgment and Release

I certify the answers I have given on this application are true and correct to the best of my knowledge.  I understand any false or misleading information provided, and any omission or concealment of facts, will disqualify me from consideration for employment, and constitutes grounds for my immediate dismissal should I be employed by the Summit Public Schools ISD #54-6.

I understand, acknowledge, and agree that no offer of employment is valid or binding until formal approval by the School Board and until such approval the Summit Public Schools ISD #54-6 shall not be liable for any reliance on any oral or written offers of employment made to me.

In connection with this application, I hereby authorize any and all former employers and references named in this application or any agent of such a former employer, to release to Summit Public Schools ISD #54-6 and its agents any and all information regarding my job performance and fitness/qualifications to perform the position I am presently seeking and any other employment or related information, both public and private, in their possession.  I understand that Summit Public Schools ISD #54-6 will use this information to determine my fitness/qualifications for the position I am seeking.  This authorization expires one year from the date of my signature, below.  I hereby release Summit Public Schools ISD #54-6 and all former employers and references listed herein and any and all agents acting on behalf of said School District, former employers or references, for any and all liability of whatever nature by reason of requesting or providing such information.

I AGREE (yes or no)

Signature

Date