RCSD - Classified Application Rev 3.2022

Name*

First NameMiddle InitialLast Name

Other Name(s): Please provide information related to change of name, assumed name, or nickname under which your credentials may be found.

Address*

Address

Street Address Line 2

CityState

Zip Code

Email address

Telephone number*

Alternative Telephone Number

Specific position(s) you are applying for*

(ie Custodian, Technology, Bus Drive, etc.)

NAME

LOCATION

DIPLOMA

Dates Attended

NAME

LOCATION

DEGREE

Dates Attended

Certifications

State Drivers Licensed Issued

Driver License Number

Current License Type and Class

License Restrictions

License Endorsements

Expiration Date

Date

Do You Possess a Yellow Card from the Indiana State School Bus Committee

YesNo

Yellow Card Number, if applicable

Employer #1 Name

Location

Position

Dates of Employment

Employer #2 Name

Location

Position

Dates of Employment

Employer #3 Name

Location

Position

Dates of Employment

Employer #4 Name

Location

Position

Dates of Employment

Please list the names of three (3) persons who know your professional background and qualification.

Name

Title

Telephone Number

Address

Street Address Line 2

City/State/Zip Code

Email Address

example@example.com

Name

Title

Telephone Number

Address

Street Address Line 2

City/State/Zip Code

Email Address

example@example.com

Name

Title

Telephone Number

Address

Street Address Line 2

City/State/Zip Code

Email Address

example@example.com

High School:

College:

Are you presently being investigated or under a procedure to consider you discharge for misconduct by your present employer?*

YesNo

Have you ever been reprimanded, disciplined, discharged, or asked to resign from a prior position?*

YesNo

Have you ever resigned from a prior position without being asked, but under circumstances involving your employer’s investigation of sexual conduct with another person, mishandling of funds, or criminal conduct?*

YesNo

Have you ever been charged with or investigated for physical sexual abuse of another person?*

YesNo

Have you ever been charged with, pleaded guilty or “no contest” to, or been convicted of, any crime involving sexual abuse of any person or any other crime of moral turpitude?*

YesNo

Have you ever been convicted of a misdemeanor and/or felony or ever entered a plea of guilty or a plea of “no contest”, or has any court ever deferred further proceedings without entering a finding of guilty or placed you on probation for a crime?*

YesNo

If you answered yes to any of the questions, please explain below. Please include the date of the incident, charge, the offense in question, the court action taken, if any, and the address of any court involved. Conviction of a crime is not an automatic bar to employment. Rossville Consolidated School District will consider the nature of the offense, the date of the offense, and the relationship between the offense and the position for which you are applying.

PERSONAL DATA EXPLANATION

I authorize the Rossville Consolidated School District to check my employment history, including without limitation, reference checks, and to seek the release of investigatory information, including criminal history, possessed by any private or public employer or any local, state, or federal agency. I authorize these private or public employers, or local, state, or federal agencies to provide the Rossville Consolidated School District any information they may release concerning the matter described herein, and I will cooperate to the extent necessary to obtain the release of this information.

I expressly waive in connection with any request for, or provision of such information, any claims or causes of action, including without limitation, defamation, infliction of emotional distress, invasion of privacy, or interference with contractual relation that I might otherwise have against the Rossville Consolidated School District, its officials, employees, trustees, or agents, or against any individual, corporate, and/or agency provider of such information. I have read this authorization and release of all claims, and I expressly agree to the terms set out herein.

Signature

Date

Rossville Consolidated School District does not discriminate on the basis of race, color, religion, sex, national origin, age, or handicapping condition, including limited English proficiency, in its educational programs or employment policies as required by state and federal laws.

ROSSVILLE CONSOLIDATED SCHOOL DISTRICT

CLASSIFIED APPLICATION FORM

BACKGROUND INFORMATION

EDUCATION AND CERTIFICATIONS

High School:

College(s):

SCHOOL BUS DRIVER APPLICANTS ONLY

EXPERIENCE

REFERENCES

ACTIVITIES

PERSONAL DATA

AUTHORIZATION AND RELEASE