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

Month Day Year
Date
PERSONAL INFORMATION
Name

First Name Last Name
EMAIL
ADDRESS
CONTACT TELEPHONE NUMBERS
CERTIFICATION INFORMATION:

Class A Class AA Class AAA Class AAAA
ENDORSEMENTS
CERTIFICATE VALID UNTIL

Month Day Year
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
EMPLOYMENT HISTORY

(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

REFERENCES

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.
GENERAL QUESTIONS
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
CERTIFIED EMPLOYEES ONLY
Are you presently under contract to any school system?

Yes No
If yes, list name of school district
Contract Ending Date

Month Day Year
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
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

Clear
Date

Month Day Year
Date
Resume and Supporting Documents

Cancel of
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.
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PERSONAL INFORMATION

EMPLOYMENT HISTORY

REFERENCES

GENERAL QUESTIONS

CERTIFIED EMPLOYEES ONLY

ALL APPLICANTS MUST COMPLETE THIS SECTION