CERTIFIED STAFF APPLICATION BON HOMME SCHOOL DISTRICT #04-2 District Office, PO Box 28, 1404 Fir Street, Tyndall, SD 57066
Name ______________________________ ______________________________ _____ Last First M.I.
Social Security Number: _____ - _____ - _____ Name as it is on Card: _____________________________________________
Position(s) for which you are applying: ___________________________________________________________________________ If we request an interview, when would be most convenient? __________________________________________________________
Present Address: ______________________________ City ____________________ State _________ ZIP ______________ At This Address Until _______________ Email Address ________________________________________________________ Home Telephone (____) _______________ Cell Phone (____) _______________ Best time to call __________
Place of Employment: ______________________________________________ May we contact you at work? _____ Yes _____ No Work Telephone (____) _______________ Best time to call __________
Permanent Address: ______________________________ City ____________________ State _________ ZIP _______________ At This Address Until _______________ Email Address ________________________________________________________ Home Telephone (____) ______________ Cell Phone (____) _______________ Best time to call __________
Teaching Certificate: Number: ______________________________ Expiration Date: ____________________ Endorsement(s): ______________________________ Teaching Majors: ______________________________ Additional Subjects/Assignments: ______________________________________________________________________________ If you do not have a certificate, will you by September 1? _____ Yes _____ No
List co-curricular activities you may be interested in directing: _______________________________________________________
Are you currently under contract with another school district? _____ Yes _____ No If yes, expiration date: _______________ May we contact your present employer? _____ Yes _____ No
Have you applied in Bon Homme #04-2 before? _____ Yes _____ No If yes, date: _______________ Were you employed in Bon Homme #04-2 before? _____ Yes _____ No If yes, date: _______________
Have you been convicted of a CRIME in the last 7 years? _____Yes _____ No (Conviction may be relevant if job related but does not necessarily bar you from employment). If yes, please explain: _________________________________________________________ ___________________________________________________________________________________________________________ BH #04-2 requires a background check (including fingerprinting) through DCI for all new employees immediately after hire.
Do you have any past or current physical or mental health conditions which may affect the performance of your work? _____ Yes _____ No If yes, please explain:
Physical Health ______________________________________________________________________________________________ ___________________________________________________________________________________________________________
Mental Health _______________________________________________________________________________________________ ___________________________________________________________________________________________________________
Are you a US citizen? _____ Yes _____ No If no, do you have a Green Card? _____ Yes _____ No
Have you ever served in the United States Armed Forces? _____ Yes _____ No If yes, indicate branch and discharge date: _________________________
Males born after December 31, 1959, are required to register for Selective Service. Are you registered? _____ Yes _____ No
List information regarding your interests, abilities, activities, and experience which you feel has a bearing on your qualifications for this position. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Write a statement about why you are interested in teaching at Bon Homme School District #04-2. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Briefly state your personal philosophy of education. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
To the Applicant A complete application includes a letter of application, resume, credentials, transcripts, and a copy of your South Dakota teaching certificate (if available). Your resume should include references (including student teaching), education, and work experience. If it does not, please list on a separate sheet of paper and attach to this application form. If your credentials do not include a recommendation from your immediate supervisor or cooperating teacher, please have that individual send a letter of recommendation. We appreciate sincerely the time and interest you have given in making application to the Bon Homme School District. We assure you that your application will receive prompt consideration. Bon Homme School District is an equal opportunity employer. The Bon Homme School District does not discriminate against any employee on the basis of sex, race, religion, national origin, age, height, weight, marital status, or handicap/disability unrelated to the employee's ability to perform his/her job.
I verify that the information given by me in this application is true, accurate, and complete. I understand that if I have given any false information on this application or if I have omitted any material fact, I may be disqualified from employment with Bon Homme School District, or if hired, I may be discharged upon discovery of such false statement(s) or omission(s). I understand that my employment with Bon Homme School District may be subject to a reference/background check. I hereby authorize Bon Homme School District to investigate the truthfulness of all statements made on this application and/or contact my former employer(s) and other listed reference(s) or any other person(s) who can verify any information submitted to Bon Homme School District in support of my application for employment. I hereby waive any right that I may have against any person contact by Bon Homme School District, including former employers who provide information concerning this application and I release each said person from liability for providing information.
________________________________________ ______________________________ Signature Date
PERSONNEL OFFICE USE ONLY Position(s) applied for___________________________________________________ Date(s) ______________________________ Interviewed by_____________________________________ Date__________ Employed: _____ No_____ Yes Date __________
EMPLOYMENT DATA RECORD
Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital status, veteran status, medical condition, handicap, or any other legally protected status. As an Equal Opportunity Employer, we comply with government regulations.
The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information, please note that all Data Records are kept in a Confidential File and are not a part of your Job Application or personnel file.
Please note: Your cooperation is voluntary. Inclusion or exclusion of any data will not affect any employment decision.
VOLUNTARY SURVEY Please Print Date ____________________
Name____________________________________________________________________________________ Last First M.I.
Street Address/PO Box: _____________________________________________________________________ City _____________________________ State __________ ZIP _______________ Social Security Number: ____________________
Current Job: _______________________________________________________________________________
Check One: _____ Male _____ Female
Age __________
Check One Of The Following (Ethnic Origin): _____White _____ Hispanic _____ American Indian/Alaskan Native _____Black _____ Other _____ Asian/Pacific Islander
Check If Any Of The Following Are Applicable: _____ Vietnam Era Veteran _____Disabled Veteran _____Handicapped Individual
OFFICE USE ONLY Position(s) applied for is open: _____ Yes _____ No Position(s) considered for: ___________________________________________________________ Date(s) __________________________________________________________________________
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