SUPPORT APPLICATION

Collinsville Public Schools

1902 West Maple

Collinsville, OK 74021

(918) 371-2326

"An Equal Opportunity Employer"

SUPPORT APPLICATION

NOTICE TO APPLICANT:

Independent School District #I-6 of Tulsa County, Oklahoma, does not knowingly discriminate against any employee or applicant for employment on the basis of race, color, sex, pregnancy, gender, gender expression or identity, national origin, religion, disability, veteran status, sexual orientation, age, or genetic information. This policy encompasses recruitment, selection, assignment, promotion, transfer, termination, compensation, training and apprenticeship and all other terms, conditions, benefits and privileges associated with employment. This policy also extends to the educational programs and activities operated by the District.

Discrimination is specifically prohibited by Title IX of the Education Amendments of 1972, as amended, and Title 45, Subtitle A, Part 86, of the impending regulations administered by the Director of the Office of Civil Rights of the United States of Health, Education and Welfare.

FIELDS MARKED BY AN ASTERISK ARE REQUIRED FOR YOUR APPLICATION TO BE SUBMITTED

Today's Date *

Name *

First Name Middle Name Last Name

Date of Birth (optional)

Month Day Year

Phone Number *

Area Code Phone Number

E-mail Address *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Type of Application *

Teacher Assistant (High School Diploma or GED Required) Special Education Paraprofessional (High School Diploma or GED Required) Administrative Assistant Certified Nurse Aide Child Nutrition: Cook (Food Handler Permit Required) Transportation Maintenance

Area of Preference *

Elementary Middle School High School No Preference

Please list any qualifications related to the position for which you are applying:

Current / Most Recent Employer

Supervisor

Position Held

Phone Number

Dates of Employment

Previous Employer

Supervisor

Phone Number

Position Held

Dates of Employment

1. Personal interviews will be arranged by the personnel office. You will receive no further reply unless you are being considered for a specific position.

2. This application will remain on file for one year. It must be renewed at that time, if so desired.

3. Each applicant should edit the data provided most carefully before submitting this form to the personnel office.

Do you agree to provide information regarding citizenship status as required by law? *

Yes No

Please select one of the boxes below regarding any legal action you may have faced. *

Entered a plea of guilty or nolo contendere to a state (any state) or federal felony charge Been convicted of a state (any state) or federal felony offense Been charged with a state (any state) or federal felony offense with was reduced to a misdemeanor offense to which you entered a plea of guilty or nolo contendere Entered a plea of guilty or nolo contendere to, or been convicted of, a state (any state) or federal misdemeanor charge involving illegal chemical substances or illegal sexual activity Entered into a deferred prosecution agreement with a state (any state) or federal prosecutor NONE

If you answered yes to any of the above questions, please list type of violation, date, place (city and state) and explanation of incident.

Name of High School *

Graduation Date *

Institution

Location

Dates Attended

Degree & Year Conferred

Institution

Location

Dates Attended

Degree & Year Conferred

CERTIFICATION

Please list Certification(s), Date of Issuance, Date of Expiration

HONORS AND ACHIEVEMENTS

Applicant should list any special honors or achievements while attending college or university.

List membership in professional organizations:

Are you in any way related to an employee of Collinsville Public Schools or a member of the Collinsville Board of Education? *

Yes No (skip this section)

If yes, please indicate who, their present position, and your relationship to that individual

Name (and Company / Positon, if applicable) *

Phone Number *

Years Known *

Name (and Company / Positon, if applicable) *

Phone Number *

Years Known *

Name (and Company / Positon, if applicable) *

Phone Number *

Years Known *

In your own words, please express your views as to why and how you could be a successful member of the Collinsville Public Schools staff. Your remarks should be limited to the space provided below.

In order that the officials of the Collinsville Public Schools may be fully informed as to my personal character and qualifications for employment, I hereby authorize Collinsville Public Schools to contact any former employer or other person whom they wish to contact concerning my personal character and qualifications and I hereby release such persons and Collinsville Public Schools from any and all liability for information provided or obtained as a result of the inquiries.

I understand that any false information or misrepresented information contained in this application may be grounds for my immediate termination.

Typing your name in the box below indicates you agree the electronic signature is the legal equivalent of your manual signature on this application.

Electronic Signature *

Date *

We are currently unable to accept resumes and certificates attached to this application. If you are being actively considered for a position, we may request those items at that time.

I. PERSONAL DATA

II. EMPLOYMENT PREFERENCE

III. EMPLOYMENT HISTORY

IV. POLICY STATEMENTS AND QUESTIONS

V. EDUCATION PREPARATION

VI. INSTITUTIONS OF HIGHER LEARNING ATTENDED

VII. MISCELLANEOUS

VIII. REFERENCES

IX. SCHOOL SERVICE