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Classified Staff Application

CLASSIFIED 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 __________

 

 

 

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 working at Bon Homme School District #04-2.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

 

ATTACH A COPY OF YOUR EDUCATION TRANSCRIPT

(High School or College)

 

EDUCATION

Name & Location                   From - To                    Degree(s)                                Date Received

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

 

 

EDUCATION REFERENCES

Full Name                               Title                             Complete Address                              Telephone

_________________________________________________________________________________________

_________________________________________________________________________________________

 

 

WORK EXPERIENCE

Begin with most recent job. Do not include part-time or summer work unless you consider it significant.

Name & Location                               From - To                    Nature of Work                       Supervisor

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

 

 

EMPLOYMENT REFERENCES

List information for those supervisors listed above in Work Experience.

Full Name                               Title                             Address, City, State, ZIP                                Telephone

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

 

 

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 

 

The 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.

 

---------------------------------------------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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