NIA FOUNDATION EMPLOYMENT APPLICATION

Position for which you are applying

Full Name*

First NameMiddle NameLast Name

Phone Number

Area CodePhone Number

Home Phone Number

Work Phone Number

Cell Phone Number

Email Address*

High School Name

Years Attended

Graduated?

YesNo

Degree / Major

College Name

Years Attended

Graduated?

YesNo

Degree / Major

Trade or Correspondence School

Graduated?

YesNo

Years Attended

Degree / Major*

Please include dates employed, Employer name, address and phone number, Position, Salary, Wage, Supervisor's name and phone number, and your reason for leaving.

Most recent position

Second most recent position

Third most recent position

Please explain any gaps in employment

Other Relevant Experience

Please list any other experience you have, including dates, employer name address and phone number, position, salary, supervisor's name and phone number, and reason for leaving.

Experience #1

Experience #2

Please list four individuals who are very familiar with your professional work and character who may be contacted. Please include their name, position, business phone, home or cell phone, and address.

References

In the field below, please respond to each of the following questions:

1. Why do you want to be a (Special Education Case Manager, Tutor, Resource Teacher, Counselor, Speech Therapist, or School Psychologist) for The NIA Foundation?

2. What experience do you have specific to the position you are applying for and how would you use that experience to be a success in The NIA Foundation?

3. Describe your greatest accomplishments as an educator.

Narrative Response

List degrees, honors, commendations, elective or appointive offices held, or other distinctions received.

HONORS AND DISTINCTIONS

Are you, or have you ever been, listed on a sex offender registry?*

YesNo

Are you, or have you ever been, listed on a child or dependant adult abuse registry?*

YesNo

Have you ever been found guilty, accepted a guilty or Alford Plea, or entered a plea of no-contest for any criminal charge?*

YesNo

Have you ever received a deferred judgment, or in some other way had a guilty plea or conviction removed from your record?*

YesNo

Have you ever received a deferred judgment, or in some other way had a guilty plea or conviction removed from your record?*

YesNo

If you answered “yes” to any of the above questions, provide date, incident, specific charge, city/state in which occurred:

Have you ever been asked to resign from a position, or been given the choice of resigning or being terminated from your position?*

YesNo

Have you ever been the subject of an investigation or other formal/informal proceeding that resulted in the termination of your employment or resignation?*

YesNo

Have you ever been the subject of an investigation into wrong doing or other formal/informal proceeding, resulting in disciplinary or criminal action?*

YesNo

Briefly explain any “yes” response(s):*

Responding "yes" to any of the previous questions is not an automatic bar to employment. The date of the offense and the relationship between the offense or infraction and the position for which you are applying will be considered.

Are you legally eligible to work in the United States?*

YesNo

Are you able to perform with or without reasonable accommodation, the essential job functions required of the position?*

YesNo

IF YES, PLEASE FILL OUT NEXT SECTION

Military Duty

Do you wish to be considered for veteran’s preference?

YesNo

Active Duty

(mm / yy)

To

(mm / yy)

Branch

Location of Duty

Rank at Discharge

Type of Discharge

Reserve Duty

(mm / yy)

To

(mm / yy)

Branch

Obligation

Times of Current Training Day

AGREEMENT (Read carefully before signing or submitting electronically)

By my signature:

• I acknowledge that individuals who provide false, inaccurate, or incomplete information in the application form, in an interview, or any other part of the hiring process or who fail to disclose information requested in the application form, in an interview, or any other part of the hiring process will not be eligible for employment, or, if they are hired, they will be subject to termination.

• I acknowledge that to the fullest extent permitted by state and federal law, The NIA Foundation hereinafter referred to as ("the Organization"), will consider all information concerning an applicant or a contractor in making hiring, termination, and other contractor-related decisions. The term "all information" includes information of any kind (verbal, written, photographic, videographic, etc.) that is accessible in any medium (print, electronic, etc.) from any source.

• I acknowledge that the Organization will consider public information and other information to which it has lawful access. This may include information that is contained in social networking sites, blogs, and other electronic sites, such as YouTube. If there is information that pertains to me that I believe requires explanation, interpretation, or clarification when it is considered by the Organization, it is my obligation to communicate this information to the Organization.

• I authorize the Organization to conduct a complete check regarding my background including, but not limited to, criminal record, child and dependent adult abuse registry screening, and sex offender registry. I agree to prepare and sign any other form necessary to complete a criminal background check. I further authorize all government agencies departments, bureaus, or related entities to release any and all information regarding my criminal history, if any. I agree to immediately notify the Organization if I should be convicted of any crime while my application is pending, or during my contracted period of employment, if hired.

• I authorize all current and former employers, teachers, and references to release all information regarding my professional competence, performance, character, and background. I waive any right I may have against any person contacted as a reference concerning this application.

• I acknowledge that information that is relevant to the Organization’s decisions will be considered regardless of the date on which the Organization obtains the information and regardless of the date on which the information was first published, created, or made accessible to the Organization.

• I understand that this application will be considered active for twelve (12) months from the date filed. I further understand that if I am employed by the Organization, this application and associated documents will become part of my permanent record.

• I understand that this application is not a contract of employment. In accepting the position, if hired, I understand that employment is at-will, unless otherwise specified by the State of California. I acknowledge that the Organization may discharge an at-will employee at any time for any legal reason or no reason at all.

Do you currently hold a valid California Teachers License with appropriate endorsement for the position you are applying for?*

YesNo

Please list your endorsements:

Are you currently under contract for any school district next year?*

YesNo

By my electronic submission of this form:

• I attest that all the information contained in this application is accurate, complete, and true.

• I am bound by all elements of the agreement section of the application.

• I understand and accept that electronic submission will be considered equivalent to an original hand written signature on a paper copy of the application.

Name

Signature

Date

1. All application materials should be returned to:

Barbara Rodriguez

533 Harvard Boulevard, #310

Los Angeles, CA 90020

2. Applicants, and/or their designees, are asked not to contact members of the Board of Directors during this search process.

3. Screening for this position will continue until the position is filled.

4. In order to be considered for this position, your application materials must include the following (please do not staple or bind your application materials):

a. A letter of application

b. Completed application form (including signatures)

c. Resume

d. Four recent letters of recommendation regarding your professional work (credentials will suffice if the information is current)

e. A copy of (or documented evidence of eligibility) a current California teacher license and endorsements

f. Photocopy of college/university transcripts

5. For further information contact:

Cescily Thomas-McKoy

Executive Administrative Coordinator

533 Harvard Boulevard, #310

Los Angeles, CA 90020

Phone: (213) 321-0371

Email: cescily@educoncepts.org

The NIA Foundation will select for employment qualified applicants for each position without improper discrimination on the basis of race, color, creed, religion, sex, sexual orientation, gender identity, national origin, ethnic background, age, or disability. Persons with disabilities who can perform the essential functions of an assignment with or without reasonable accommodation shall be considered qualified applicants. The organization shall take affirmative action in the recruitment, appointment, assignment, and advancement of personnel to accomplish the goals of equal employment opportunity. In keeping with the law, the organization shall consider the veteran status of applicants.

Personal Information

Experience

Background Information