Gregory School District 26-4 Classified Staff Application

Phone: (605)835-9672 Fax: (605)835-8146 www.gregory.k12.sd.us
Gregory School District 505 Logan Ave Gregory, SD 57533

Applicants are requested to fill this form out in its entirety. Please mail your completed application to the address above or send your application via e-mail to sara.anderson@k12.sd.us.

Name

Social Security Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Cell Phone

Please enter a valid phone number.

Email

example@example.com

Preferred Contact Method

Military Preference

Are you legally eligible for employment in the U.S.A?

Are you able to perfor the essential functions of the position with or without accommodations?

Position(s) applying for

Education

Name of School: blanks Dates attended:blanks : blank
Degree: blank Major or Minor blanks

Previous Employment - list most recent first (list up to 3)

Name of business: blanks Contact Number: blank
Dates of employment blanks: blank Job title: blank

List any professional licenses, certifications or registrations

List any other skills or information regarding the position you wish to share

Please list 3 references other than relative and previous employers

Name: blanks Posistion: blanks Company: blank
Telephone number: blank E-mail: blanks

1) Are you able to perform the essential job functions which may or may not require a reasonable accommodation?

2) Can you, after employment, submit verification of your legal right to work in the United States?

3) Have you ever been convicted of any offense, felony or misdemeanor, other than a traffic violation that did not result in suspension or revocation of driver's license?

4) Do you now have any charges against you which have not been adjudicated?

5) Have you ever resigned from or otherwise left a public or private school employment to avoid investigation for alleged misconduct and/or dismissal in South Dakota or any other state or place?

6) Have you ever been dismissed or not reemployed in any probationary or permanent teaching position?

7) Are you now a subject of any injury, disciplinary action, review or investigation, in any district, by a teacher licensing agency, or in the courts of South Dakota or any other state in connection with any alleged misconduct?

8) Have you ever had any credential, application, permit, license, or other document authorizing public school service or teaching suspended, revoked, voided, denied and/or otherwise rejected for cause in South Dakota or in any other state?

9) Is any adverse action now pending against any credential you hold which authorizes public school service or teaching in South Dakota or any other state?

10) Have you ever pleaded guilty, or been convicted or entered a plea of nolo contendere?

State law requires that all applicants prior to employment be fingerprinted and prohibits employment of any person convicted of certain sex offenses, narcotic offenses, and violent crimes. Answering "Yes" to any questions 3-10 above is not an absolute bar to employment. If you answered "Yes" to any questions 3-10 above, fill out the comment box below to explain your answer(s)

Applicants Signature

Date

The Gregory School District is an equal opportunity employer and is non-discriminating in its educational