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

TeacherTeacher AssistantCustodianSecretaryCafeteria WorkerMaintenanceOther
NAME OF POSITION
DATE

MonthDayYear
Date
PERSONAL INFORMATION
Name

First NameLast Name
EMAIL
ADDRESS
CONTACT TELEPHONE NUMBERS
Format: (000) 000-0000.
CERTIFICATION INFORMATION:

Class AClass AAClass AAAClass AAAA
ENDORSEMENTS
CERTIFICATE VALID UNTIL

MonthDayYear
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?

YesNo
If so, what state?

Education

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

Subjects of special study or research work
EMPLOYMENT HISTORY

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

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

REFERENCES

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

Rows	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.
GENERAL QUESTIONS
Have you ever applied in this district?

YesNo
If so, When?
Are you presently enrolled in the State Employees Health Program?

YesNo
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?

YesNo
6. Are you a veteran?

YesNo
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?

YesNo
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?

YesNo
Are you presently the subject of any pending criminal charges?

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

YesNo
If yes, explain
Are you currently addicted or dependent on alcohol?

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

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

YesNo
Do you have a valid CDL license?

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

YesNo
CERTIFIED EMPLOYEES ONLY
Are you presently under contract to any school system?

YesNo
If yes, list name of school district
Contract Ending Date

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

YesNo
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?

YesNo
If yes, explain
Are you currently pursuing a higher degree or an additional area of certification?

YesNo
ALL APPLICANTS MUST COMPLETE THIS SECTION
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
Date

MonthDayYear
Date
Resume and Supporting Documents

Cancelof
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.
Should be Empty:

PERSONAL INFORMATION

EMPLOYMENT HISTORY

REFERENCES

GENERAL QUESTIONS

CERTIFIED EMPLOYEES ONLY

ALL APPLICANTS MUST COMPLETE THIS SECTION