APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

AMITE COUNTY SCHOOL DISTRICT

533 Maggie Street ∙ Liberty, MS 39645 ∙ 601-657-436

Don Cuevas, Superintendent

www.amite.k12.ms.us

All new perspective employees must be fingerprinted. All employees may be subject to a drug test. These procedures must be done by our district personnel. (You will be responsible for a $25.00 fingerprint fee.)

TYPE OF POSITION APPLYING FOR

Teacher Teacher Assistant Custodian Secretary Cafeteria Worker Maintenance Other

NAME OF POSITION

DATE

Date

Name

First Name Last Name

EMAIL

ADDRESS

CONTACT TELEPHONE NUMBERS

CERTIFICATION INFORMATION:

Class A Class AA Class AAA Class AAAA

ENDORSEMENTS

CERTIFICATE VALID UNTIL

Date

MS LICENSE NUMBER

YRS EXPERIENCE

Are you presently employed?

If so, may we inquire of your present employer?

Are you retired from another state?

Yes No

If so, what state?

Education

	NAME & LOCATION OF SCHOOL	YEARS ATTENDED	DATE GRADUATED	DEGREE OBTAINED
High School
College
Trade, Business, Correspondence Schoo

Subjects of special study or research work

(List below the last four employers, beginning with the most recent)

	DATES EMPLOYED	NAME & CONTACT INFORMATION FOR EMPLOYER	SALARY	POSITION	REASON FOR LEAVING
1
2
3
4

Please list four references who are not related to you, at least one must be a former employer.

	NAME	EMAIL ADDRESS	TELEPHONE NUMBER	RELATIONSHIP	YEARS ACQUAINTED
1
2
3
4

The Amite County School District is an equal opportunity employer. We will not discriminate and will take affirmative action measures to ensure against discrimination in employment, recruitment, advertisements for employment, compensation, termination, upgrading, promotions, and other conditions of employment against any employee or job applicant on the basis of race, color, gender, national origin, age, religion, creed, disability, veterans’ status, sexual orientation, gender identity or gender expression.

Have you ever applied in this district?

Yes No

If so, When?

Are you presently enrolled in the State Employees Health Program?

Yes No

Give the approximate number of days you missed, for illness or otherwise, for a one year period in your last full-time employment.

5. Are you able to perform essential functions of this job without accommodations?

Yes No

6. Are you a veteran?

Yes No

If yes, list branch of service, period of active duty and rank

List any special talents you have that may be beneficial to you in the position for which you have applied.

List professional organizations of which you are a member.

Briefly describe why you wish to secure a position at the Amite County School District.

Have you ever been arrested, convicted of or pled guilty or nolo contendere to any crime, other than a minor traffic violation?

Yes No

If yes, state the name and address of the Court, the date of the alleged offense, a description of the charges and an explanation of the final action taken, including any fines, probation, imprisonment, or similar description.

Have you ever been arrested or charged with any crime or been named in an indictment, accusation or special presentation for any offense, other than a minor traffic violation?

Yes No

Are you presently the subject of any pending criminal charges?

Yes No

Have you ever been asked to resign, been discharged, non-renewed or terminated from any previous employment?

Yes No

If yes, explain

Are you currently addicted or dependent on alcohol?

Yes No

Are you currently addicted or dependent on other habit-forming drugs?

Yes No

Are you a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or other drugs having similar effects?

Yes No

Do you have a valid CDL license?

Yes No

I agree to be drug/alcohol tested if I am involved in any type of accident involving this school district?

Yes No

Are you presently under contract to any school system?

Yes No

If yes, list name of school district

Contract Ending Date

Date

Do you have current recommendations on file in a college teacher placement office?

Yes No

List co-curricular activities that you are qualified and prepared to coach or direct

List college and/or community activities and honors engaged in or received before and since graduation.

Have you ever had a professional certificate/license revoked?

Yes No

If yes, explain

Are you currently pursuing a higher degree or an additional area of certification?

Yes No

By my signature, I attest that the information contained in this application is true and represents me accurately. I authorize investigation of all statements contained herein as may be necessary in arriving at an employment decision. I understand that any false or misleading information given in this application or interview(s) may result in me not being considered for the position(s) for which I have applied or if employed may result in my termination. I understand that the application will remain in the personnel files of the Amite County School District for 12 (twelve) months from the date of application and will then be destroyed.

Signature

Clear

Date

Resume and Supporting Documents

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The Amite County School District is an equal opportunity employer. We will not discriminate and will take affirmative action measures to ensure against discrimination in employment, recruitment, advertisements for employment, compensation, termination, upgrading, promotions, and other conditions of employment against any employee or job applicant on the basis of race, color, gender, national origin, age, religion, creed, disability, veterans’ status, sexual orientation, gender identity or gender expression.

PERSONAL INFORMATION

EMPLOYMENT HISTORY

REFERENCES

GENERAL QUESTIONS

CERTIFIED EMPLOYEES ONLY

ALL APPLICANTS MUST COMPLETE THIS SECTION