ESU 1 Job Application

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Please complete the form below to apply for a position with us.
Full Name:*

First NameLast Name
Position Desired:*
Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:*
Phone Number:*
Format: (000) 000-0000.
YESNO
YESNO

Education

Please fill out all rows that apply:*

Rows	Name of School	City, State	Graduation Year	Type of Degree
High School Education
College Education
College Education
College Education

Graduate Credit Hours Earned Beyond Degree? (If Applicable)
Area of Study:

Training, Certification and Licensure
YESNO

If "YES", please complete the following:

Rows
State Name:
Expiration Date:
Endorsements:

YESNO

If "YES", please complete the following:

Rows
State Name:
Expiration Date:
Endorsements:

Please list any additional education, training, certification and/or experience specifically relevant to position:

Employment Experience
Employer:Employer Name
Address: Address
Position Held:   Position
Supervisor Name:    Name
Dates of Employment: blanks
Phone Number:
Salary:
May we contact?
Reasons for Leaving: blanks
Job Duties: blank
Employer:Employer Name
Address: Address
Position Held:   Position
Supervisor Name:    Name
Dates of Employment: blanks
Phone Number: blank
Salary: Type a label
May we contact?
Reasons for Leaving: blanks
Job Duties: blank
Employer:Employer Name
Address: Address
Position Held:   Position
Supervisor Name:    Name
Dates of Employment: blanks
Phone Number: blank
Salary: Type a label
May we contact?
Reasons for Leaving: blanks
Job Duties: blank
YESNO
Please specify:

Professional References

Please provide contact information for references:*

Rows	Name:	Relationship:	Telephone Number:
Professional Reference:
Professional Reference:
Professional Reference:

Personal Disclosure
Respond to EACH item. If there is no response to any item, or if the required attachments do not accompany your application, your application WILL BE REMOVED FROM CONSIDERATION. Information provided in this disclosure will not automatically bar you from employment but will be considered in view of all relevant circumstances.
- Have you ever received a ticket, been charged with an offense, been arrested or been convicted for criminal offense relating to sexual or physical abuse?
- If "Yes", please explain each situation including location(s), date(s), agency(ies) involved, and the outcome of each ticket, charge, or arrest: Explain
- Have you ever had any license, permit, or certificate terminated, revoked, suspended, received a private or public reprimand or admonishment from a licensing agency or been subject to a judicial restraining or contempt order?
- If "Yes", please explain each situation including location(s), date(s), agency(ies) involved, and the outcome of each situation: Explain
- Have you ever been involuntarily terminated or asked to resign, or resigned in lieu of termination from employment?
- If "Yes", please explain each situation including the name of the employer(s), date(s) and the reason(s) for the resignation or termination: Explain

Consent and Certification
I HEREBY AUTHORIZE Educational Service Unit #1 to make any investigation of my personal history and criminal records through any investigative agencies of their choice. This includes any educational institution, government agency, Child/Abuse/Neglect Registry or any other person having any records or information concerning me to furnish such records or information requested to Educational Service Unit 1. In making this application for employment, I also understand that an investigative consumer report may be made whereby information is obtained through interviews of persons with whom I am acquainted. This investigation may include, but is not limited to, such information as criminal or civil convictions, driving records, previous employment and education, personal references, professional references and other appropriate sources.

I FURTHER AUTHORIZE AND GIVE CONSENT to anyone contacted for the purpose of obtaining such information during the course of the investigation as described above to provide relevant information and opinions about me and to release and discuss all records and information they may have pertaining to my consideration for employment at Educational Service Unit 1. Such persons may include, but are not limited to, individuals listed as references, previous employers, law enforcement agencies and the courts. I hereby release such persons who may give or receive information pursuant to this authorization from any legal liability and from any and all claims of any kind. I further waive my right of access to any such information or any liability with its release or use.

I FURTHER CERTIFY that I have made true, correct and complete answers and statements on this application in the knowledge that they may be relied upon in considering my application. I understand it is my responsibility to immediately provide updated, correct information if any of the information changes at any time. I understand that any omission, falsification or misrepresentation made by me on this application or any supplement will be sufficient grounds for failure to employ me or for my discharge should I become employed with Educational Service Unit #1. I understand that disclosure of social security number is optional. It will be used to conduct background checks for employment purposes and for personnel and payroll processing and required reporting if I am employed.

I UNDERSTAND that any offer of employment may be conditioned on a criminal background check and execution of a written contract/agreement of employment. I further understand that employment in a classified position would be on an at will basis, terminable at will.

Educational Service Unit #1 does not discriminate based on gender, race, national origin, creed, age, marital status, sexual orientation, veteran status or disability. This position is subject to a veteran’s preference. Persons requiring accommodations to apply and/or be considered for positions with Educational Service Unit #1 are asked to make their request to the Administrator. Inquiries and grievances may be directed to the Administrator at Educational Service Unit #1, 211 Tenth Street, Wakefield, NE 68784-5014, (402) 287-2061.
Signature:*

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Date:*

MonthDayYear
ELECTRONIC SUBMISSION CONSTITUTES AGREEMENT AND SIGNATURE AN ORIGINAL SIGNATURE MAY BE REQUIRED UPON EMPLOYMENT

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Upload Additional Documents

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Complete application and supporting documentation provided will be retained for one year from the date of receipt.

All personally identifiable data items received by Educational Service Unit #1 as a part of the foregoing application will be considered confidential and maintained in a manner that will assure confidentiality. Personally identifiable data items, such as credentials, references, etc., shall not be released to another party or class of parties without your prior written permission.
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Education

Training, Certification and Licensure

Employment Experience

Employer:Employer Name Address: Address Position Held: Position Supervisor Name: Name

Dates of Employment: blanks Phone Number: Salary: May we contact? Please Select YES NO

Reasons for Leaving: blanks Job Duties: blank

Employer:Employer Name Address: Address Position Held: Position Supervisor Name: Name

Dates of Employment: blanks Phone Number: blank Salary: Type a label May we contact? Please Select YES NO

Reasons for Leaving: blanks Job Duties: blank

Employer:Employer Name Address: Address Position Held: Position Supervisor Name: Name

Dates of Employment: blanks Phone Number: blank Salary: Type a label May we contact? Please Select YES NO

Reasons for Leaving: blanks Job Duties: blank

Professional References

Personal Disclosure

Consent and Certification

Employer:Employer Name
Address: Address
Position Held: Position
Supervisor Name: Name

Dates of Employment: blanks
Phone Number:
Salary:
May we contact?

Reasons for Leaving: blanks
Job Duties: blank

Employer:Employer Name
Address: Address
Position Held: Position
Supervisor Name: Name

Dates of Employment: blanks
Phone Number: blank
Salary: Type a label
May we contact?

Reasons for Leaving: blanks
Job Duties: blank

Employer:Employer Name
Address: Address
Position Held: Position
Supervisor Name: Name

Dates of Employment: blanks
Phone Number: blank
Salary: Type a label
May we contact?

Reasons for Leaving: blanks
Job Duties: blank