Classified Application Form

Date*

Date

Position for which you are applying*

Personal Information

Name:*

First NameLast Name

Phone Number:*

Area CodePhone Number

E-mail Address:*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number:

Current Position:*

Where do you currently work?

Current Salary:*

Current Annual Salary

Date available for employment*

Date

High School Name:*

Years Attended:*

Graduation Date*

Date

College Name:

Years Attended:

Graduation Date

Date

Degree/Major:

Work Experience

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:

Fourth 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 3:

References

Please list three 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 email address.

Reference 1

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Reference 2

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Reference 3

Name:*

First NameLast Name

Phone Number*

Area CodePhone Number

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Letters of Recommendation:

Upload a File

Resume:

Upload a File

Cover Letter:

Upload a File

Transcript:

Upload a File

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

1. Why do you want to work for the Iron County C-4 Schools?

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 Iron County C-4 Schools?

Narrative Response:*

Background Information

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 dependent 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

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):

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

AGREEMENT (Read carefully before signing or submitting electronically)

By my signature I submit:

Terms and Release Authorization

1. The information disclosed will be made available only to appropriate district officials.

2. You must complete all sections of this application form. If employed, making false statements or omitting information, may be grounds for dismissal.

3. I hereby authorize representatives of the Iron County C-4 School District to contact all persons and entities listed on this application form and to make all other contacts, inquiries and investigations which they deem necessary in order to verify my education, employment and criminal and child abuse history, including but not limited to contacting current and, or past employers, educational institutions, law enforcement, and child abuse agencies. I hereby consent to the release of any such information by third persons and I understand that the Iron County C-4 School District will keep such information in a confidential file, available only to appropriate district officials.

I hereby release and hold harmless the directors, officers, employees, and agents of Iron County C-4 School District; each of my past employers; and any other person or entity providing information to the Iron County C-4 School District and/or members in connection with my application for employment, from any and all liability arising from disclosure of personnel records and/or from oral appraisals of my past performance made to the Iron County C-4 School District.

I understand that employment with Iron County C-4 School District is contigent upon the satisfactory completion of a criminal and child abuse/neglect record check. In accordance with State law, this background check will include a complete fingerprint criminal records check. An unsatisfactory report shall constitute cause for rejection of an application or immediate termination, if the applicant has been hired. Although the existence of an arrest, charge, plea, convictions, and/or sentence alone may not constitute an unsatisfactory report, an Iron County C-4 School District member has a compelling interest in ensuring the safety and welfare of its students. Therefore, an obligation, to request criminal and child abuse/neglect information and official records for each applicant and employee, and to act in accordance with such information and official records.

I hereby certify that all information provided by me in connection with this application is true, accurate, and complete. I understand that any false, inaccurate, incomplete, omitted, or misleading information provided on this application, or on any other documents submitted in connection with this application, shall be the cause for refusal to hire, or if the applicant has been hired, for immediate termination.

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*

First NameLast Name

Signature*

Date*

Date