PCSC Non-Certified Application

Date of Application

Date

Name (Last, First)

Maiden

MI

Address

Street Address

Street Address Line 2

CityState

ZIP

Phone (Home/Cell)

Email

example@example.com

Select the Position(s) for which you would like to be considered:

Will you accept Full-Time employment?

Will you accept Part-Time employment?

Will you be available to substitute for the position indicated above?

Available Start Date:

Date

Your availability Monday thru Sunday (with times):

Experience

Rows	Name and Address of Previous Employer (Most Recent Listed First)	Position(s) Held	Employment Start and Ed Dates	Immediate Supervisor and Phone Number
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Education

Rows	School Name, City, & State	Dates Attended	Degree Earned
High School
High School
Vocational/College
Vocational/College
Other

1.

2.

3.

4.

5.

Write a brief statement explaining why you are applying for a position within Pike County School Corporation:

Give at least three(3) references, including supervisors and officials under whom you have worked. Please indicate if the individual listed is a work or personal reference.

Rows	Reference Name, City & State	Position	Type of Ref.	Phone	Email
1
2
3
4
5
6

1. Are you presently being investigated or under a procedure to consider your discharge for misconduct by your present employer?

2. Have you ever been reprimanded, disciplined, discharged or asked to resign from a prior position?

3. Have you ever resigned from a prior position without being asked, but under circumstances involving your employer's investigation of sexual misconduct with another erson, mishandling of funds or criminal conduct?

4. Have you ever been charged with or investigated for physical or sexual abuse of another person?

5. Have you ever been charged with or investigated for physical or sexual abuse of another person?

6. Have you ever been convicted of a misdemeanor and/or felony, or ever entered a plea of guilty or a plea of "no contest", or has any court ever deferred proceedings without entering a finding of guilty or placed you on probation for any crime?

If you answered yes to any one of the previous six questions, please explain in the box below, include the date of the incident, charge, court action taken, the offense in question and the address of any court involved. Answering yes to this question does not necessarily disqualify you from employment.

I attest that the information included in this application is true to the best of my knowledge. My signature below constitutes my authorization, waiver, and release for the Pike County School Corporation to check, and for all prior employers, supervisors, educational institutions, and state and federal agencies, and their present and former employees and agents, to divulge information relating to my qualifications for employment. Such information includes, but is not limited to, criminal history, information maintained by any teacher licensing agency, job performance evaluations, personnel file information, anecdotal records in the possession of supervisors, and any settlement agreement, by whatever name called, which resolved issues regarding my employment and any internal transfer or departure there from regardless of whether or not said agreement called for confidentiality.

My signature below also constitutes my express, voluntary waiver and release of any and all legal claims or causes of action against any and all state or federal agencies and present and former employers and their present and former employees and agents who sought or provided the above-indicated information, including the Pike County School Corporation to which I make this application for employment. Said claims or causes of action include, but are not limited to defamation, infliction of emotional distress, invasion of privacy, interference with contractual relations, and breach of contract. Further, said signature is my express, voluntary promise to hold said entities and individuals harmless from any and all liability, costs, or damages, including fees, resulting from said legal claims or causes of action. I have read and understood this Authorization, Waiver, and Release and expressly and voluntarily agree to its terms.

Signed By:

Date

Browse Files

Work Experience

Education

List Additional Skills and/or Qualifications

References

OTHER QUESTIONS

AUTHORIZATION AND RELEASE