Cape Flattery School District 401 P.O. Box 109, Sekiu, WA 98381

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Cape Flattery School District 401
P.O. Box 109,
Sekiu, WA 98381
CLASSIFIED PERSONNEL APPLICATION FORM
PLEASE PRINT THIS SECTION
Date of Application:
Date Available
Name
(Last)
(First)
Present Address
Permanent Address
Home Phone (
SS #
(Middle)
-
-
(Street)
(City)
(State)
(Zip)
(Street)
(City)
(State)
(Zip)
)l
Work Phone (
E-Mail Address:
)
Present Employment Status
JOB PREFERENCE
POSITIONS FOR WHICH YOU ARE APPLYING:
Secretarial-Clerical
Maintenance
Food Service
Para-Educator
Custodial
Bus Driver
Substitute Only (Check areas in which you are willing to sub.)
Other
EDUCATION/TRAINING
Name of School & Location
Course of Study
GPA
Dates Attended
High School
College or University
College or University
Business School
Vocational School
Are you a member of the Washington Teachers' Retirement System?
Are you a member of the Public Employees' Retirement System?
Are you a member of the School Employees' Retirement System?
First Aid Training (Levels)
Bus Drivers Only:
No
Yes #
No
Yes #
No
Yes #
Card Expiration Date:
Do you have a Commercial Drivers License Endorsement?
Food Service Only: Do you hold a valid Food Handlers Permit?
Yes
Yes
No
No
Para-Educator Only: Have you completed at least 72 quarter hours or earned an associates degree or higher
OR
from an institution of higher education?
Have you taken the Para-professional on line test?
Score:
Yes
Yes
No
No
Note: Classified Para-educator positions require college transcripts be attached if applicable.
EMPLOYMENT EXPERIENCE
Give past employment record as completely as possible starting with your present or latest employer.
Include summer employment. (If space is insufficient, list on a separate page or attach resume.) For any
unemployed or self-employed periods, show dates and locations.
Approx.
Dates
From:
To:
From:
To:
From:
To:
From:
To:
Employer's Name, Address, Zip,
Phone Number
To:
Reason Left
Address
Phone (
)
Name
Address
Phone (
)
Name
Address
Phone (
)
Name
Address
)
Name
Address
Phone (
From:
Position Held
Name
Phone (
From:
Supervisor/
Title
)
Name
Address
To:
Phone (
)
REFERENCES
Give at least three work-related references that have first-hand knowledge of your character, personality,
scholarship, para-professional or technical ability.
Name
Address
Official Position
Phone
T
The Cape Flattery School District complies with all federal and state laws and regulations and does not discriminate on the
Cape Flattery
District
No. 401
is an sex,
equalsexual
opportunity
employerreligion,
and employs
without
to status.
race, creed,
basis
of race,School
ethnicity,
national
origin,
orientation,
age, individuals
disability and
/or regard
veteran
Thiscolor,
holdsnational
true
origin,
sex,employment
marital status,
or handicap/disability.
This policy
complies
with all applicable
and federal
rules andshould
regulations.
for
all age,
district
and
opportunities. Inquiries
regarding
compliance
and /orstate
grievance
procedures
be directed
Inquiries regarding compliance and/or grievance procedures may be directed to the school districts Title IX/RCW 281.640 Officer and/or the
to the school district's Title IX compliance coordinator and/ or Section 504 /ADA coordinator, C/O Cape Flattery School District,
Section 504 Coordinator, P.O. Box 109, Sekiu, WA 98381
Box 109, Sekiu, WA 98381. (360) 963-2329.
__________________
APPLICATION INFORMATION FOR CLASSIFIED POSITIONS
1.
Candidates are required to submit the following:
•
A completed district application form and supplemental Inserts A and B. Insert C is optional.
•
Copies of the any college transcripts if applicable. Unofficial transcripts may be submitted as
part of the application. Official transcripts will be required of all appointed candidates.
•
A letter of application indicating your interest in the job and any special qualifications you wish
us to consider.
•
Any other information that the candidate feels worthwhile for consideration.
2.
The administrative staff with other selected staff personnel will examine the applications of
candidates for open positions and select finalists for interview based on information in application
materials.
3.
Finalists will be scheduled for interviews and/or and their references will be contacted. Citizenship:
Pursuant to federal law, candidates must provide evidence of citizenship and verification of
identification if selected for interview.
4.
The superintendent will issue an offer to the candidate selected for the position. All employees are
required to obtain fingerprint clearance from Washington State Patrol and the FBI at their own
expense. Fingerprinting is available at the District Office.
5.
Following board approval, the superintendent will issue an offer to the candidate of his/ her
employment and issue a contract or other employment document. Employment is conditional until
the results of the background check are received by the district.
Your application will be kept on file for one year. After one year from the date of the application, the active
file of applications will be cleared. If you wish to continue to be considered for employment, you should
renew your application for each open position by submitting another application or by sending a letter
requesting consideration for the specific opening. It is not possible to interview everyone who makes a
request. Only finalists will be requested to appear for an interview.
CONDITIONAL EMPLOYMENT STATUS
I
understand and agree that my employment, if hired, with the Cape Flattery
School District is conditional until the District completes the background check and informs me that, based
on the results of that background check, my employment will continue or will terminate. Until such
time as the background check is completed, my employment shall only be as a casual day-to-day employee
and neither that employment, nor any acts, written agreements or other representations by the District or its
representatives, shall in any way bind or require the District to continue my employment. I also understand
that the cost of such background check is my responsibility. The cost of processing the fingerprints will be
required at the time I am fingerprinted.
Signature ________________________________ Date _________________________________
_____________________________________________________________________________________
CERTIFICATION, AUTHORIZATION AND RELEASE
My signature below authorizes the school district to conduct a background investigation and authorizes the
release of information in connection with my application for employment. The investigation may include
such information as criminal or civil convictions, driving records, previous employers and references, and
other appropriate sources. I waive my right of access to any such information and without limitation hereby
release the school district and the reference sources from any liability in connection with its release or use.
Furthermore, I 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 that
any omission, falsely answered statements made by me on this application or any supplement to it will be
sufficient grounds for failure to employ or for discharge should I become employed with the Cape Flattery
School District.
Applicant Signature _______________________________
Date ____________________________
ONLY THOSE SELECTED FOR AN INTERVIEW WILL BE CONTACTED.
APPLICANT: Please complete the middle box in the areas that have been marked with an *, sign where
indicated and return with your application.
INSERT A
To:
WASHINGTON STATE SEXUAL MISCONDUCT DISCLOSURE RELEASE
School District Employer:
Personnel Department:
Mailing / Street Address:
City, State and Zip:
The named applicant is under consideration for a position in our district. The Legislature has
determined that additional safeguards are necessary in the hiring of school district employees to
ensure the safety of Washington's school children. The individual whose name appears below
has had previous employment with your organization. As a former employer, we request you
provide the information requested on this form within 20 business days as required by state law
(RCW 28A.400). Sexual misconduct definitions are found in WAC 180-87-080. Your assistance
is appreciated.
Evelyn Wonderly, Human Resources
Cape Flattery School District
Box 109 / 13- 193 HWY 112
Return all completed information to:
Sekiu, WA 98381
Employing School Receipt Date: __________ Recipient Name: ___________________________
*Applicant's Name (First, Middle, Last):
*Full Name When Last Employed With Organization:
*Social Security Number:
*Certificate #
Approximate Dates of Employment:
Position(s):
I authorize you to release to the school/district listed above, all information related to any acts of
sexual misconduct that the school district has made a determination that there is sufficient
information to conclude that the abuse or misconduct occurred and that the abuse or misconduct
resulted in the employee's leaving his or her position at the school district. Such information
includes copies of all related documents, including any rebuttal documents, in personnel,
investigative or other files, in accordance with RCW 28A.400. I release the above employer and
employees acting on behalf of the employer from any liability for providing information described
in this document.
*____________________________________
*______________________________
Date
Applicant's Signature
No sexual misconduct materials were found.
Yes. Sexual misconduct materials are available. Please contact for more information.
Complaint of Sexual Misconduct was filed with OSPI.
Yes
No
No record of employment.
_________________________________
Former Employer Signature Title Date
_________________________
___________
INSERT B
CAPE FLATTERY SCHOOL DISTRICT NO. 401
APPLICANT* DISCLOSURE STATEMENT
Reference RCW. 28A.400, RCW 3.43
Please complete the following questions and sign the declaration. Any falsification or deliberate
misrepresentation, including omission of a material fact, or failure to complete any part of your
application or this questionnaire can be grounds for denial of employment or continued
employment with the district.
ALL REQUIRED DOCUMENTATION REQUESTED BELOW MUST ACCOMPANY THIS FORM.
AL QUESTIONS MUST BE ANSWERED. IF ADDITIONAL SPACE IS NEEDED, ATTACH A
SEPARATE SHEET OF PAPER.
EMPLOYMENT HISTORY DISCLOSURE
1. Are you authorized to work in the United States?
Yes
No
(Documentation of authorization to work in the U.S. will be required if an offer of employment is made and accepted.)
2. Are you a former employee of our District?
No
Yes
If yes, list dates and positions:
3. Have you ever been on a plan of improvement or placed on probation?
No
Yes
4. Have you ever been placed on administrative leave pending investigation of allegations of
misconduct?
No
Yes
5. Have you ever resigned or otherwise separated from any employment (inclusive of regular or
extracurricular positions) in order to avoid discharge?
No
Yes
6. Have you ever been discharged from any employment (inclusive of regular or extracurricular
positions?
No
Yes
7. Have you ever been disciplined for misconduct by a past or present employer?
No
Yes
8. If you answered YES to any of questions 4, 5, 6, 7 or 8, provide an explanation of
the circumstances, including the underlying facts, place, date and outcome. Attach an
additional page if needed.
*All prospective employees who will or may have unsupervised access to children under 16 years of age, developmentally
disabled persons, and/or vulnerable adults are "applicants."
Page 1 of 3
INSERT B
APPLICANT DISCLOSURE STATEMENT
CRIMINAL HISTORY DISCLOSURE
1. Are you presently charged with, but no convicted of, a crime? (Exclude civil infractions,
such as minor traffic citations.)
Yes If yes, attach an explanation of the
No
nature of the charge, place, date, and court. A pending criminal charge will not
necessarily bar you from District employment.
2. Have you ever been convicted of a crime? (The term "convicted" means all adverse
dispositions, including a finding of guilt, a plea of guilty or nolo contendere, an Alford
plea, a stipulation to the facts, a deferred or suspended sentence, or a deferred
prosecution. Exclude civil infractions, such as minor traffic citations.)
No
Yes
If yes, attach an explanation of the nature of the crime, place, date, and court. A
conviction record will not necessarily bar you from District employment.
3. (A) Check any of the following for which you have been convicted, including any of
these crimes as they may have been renamed: (See above for definition of
"convicted".)
First, Second, or Third Degree
Child Molestation
First or Second Degree
Sexual Misconduct with
Minor(s)
Patronizing a Juvenile Prostitute
First or Second Degree
Manslaughter
First, Second, or Third Degree
Rape
Selling or Distributing Erotic
Material to Minor(s)
Sexual Exploitation of Minor(s)
Indecent Liberties
Communication with a Minor
For Immoral Purposes
First Degree Arson
Vehicular Homicide
First Degree Burglary
Malicious Harassment
Child Abuse or Neglect
Defined in RCW 26.44.020
Violation of Child Abuse
Restraining Order
Child Buying or Selling
Aggravated Murder
Criminal Abandonment
First or Second Degree Murder
First or Second Degree Criminal
Mistreatment
Promoting Pornography
First or Second Degree
Kidnapping
First or Second Degree
Custodial Sexual Misconduct
Custodial Assault
First, Second, or Third
Degree Assault of Child
First, Second, or Third
Degree Assault
Simple Assault
First or Second Degree
Custodial Interference
Incest
First, Second, or Third
Degree Rape of a Child
Child Abandonment
(B)
First or Second Degree Extortion
First or Second Degree Robbery
Felony Indecent Exposure
Unlawful Imprisonment
First Degree Promoting
Prostitution
Prostitution
CHECK HERE IF YOU HAVE NOT BEEN CONVICTED OF ANY OF THE ABOVE,
INCLUDING ANY OF THESE CRIMES AS THEY MAY HAVE BEEN RENAMED.
4. Have you ever been (a) found by a court in a protection proceeding under Chapter 74.34
to have abused or financially exploited a vulnerable adult or (b) convicted of any of the
following crimes where the victim was a vulnerable adult: (Vulnerable adult means adults of
any age who lack the functional, mental or physical ability to care for themselves.)
•
First, Second, or Third Degree Extortion
Forgery
•
First Second or Third Degree Theft
Any of the foregoing crimes as they may have
•
First Second or Third Degree Robbery been renamed
ANSWER:
Page
NO
YES
If yes, explain below.
2 of 3
5. Have you ever been convicted of any crime involving the manufacture, delivery, or
possession with intent to manufacture or deliver a controlled substance?
ANSWER:
NO
YES
If yes, explain below.
6. Have you ever been found in any dependency action under RCW 14.34.040 to have
sexually assaulted or exploited any minor or to have physically abused any minor?
ANSWER:
NO
YES
If yes, explain below.
7. Have you ever been found by a court in a domestic relations proceeding under Title 26
RCW to have sexually abused or exploited any minor, or to have physically abused any
minor?
ANSWER:
NO
YES
If yes, explain below.
8. Have you ever been found in any disciplinary board final decision to have sexually or
physically abused any minor or developmentally disabled person, or to have abused or
financially exploited any vulnerable adult? "Disciplinary board final decision" means (a)
any final decision by the director of the Department of Licensing for real estate brokers
and salespersons and (b) any final decision by a disciplinary authority under Chapter
18.130 RCW or the secretary of the Department of Health for the following businesses or
professions: chiropractic, dentistry, dental hygiene, naturopathy, massage, midwifery,
osteopathic medicine and surgery, physical therapy, physicians, practical nursing,
registered nursing and psychology.
ANSWER:
NO
YES
If yes, explain below.
9. Are you presently charged with, but not convicted of, any of the crimes or offenses
described in questions 1 through 8 above?
ANSWER:
NO
YES
An inquiry may be made to the Washington State Patrol, a Federal, or other Law enforcement
agency to verify your responses to the above inquiries. A copy of any response received
pursuant to such inquiry will be made available to you upon request.
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is
true and correct.
Applicant Print Name:
Applicant Signature: ________________________________________________________
Date and Place:
Page
3 of 3
Cape Flattery School District No. 401
Optional Confidential Data Form
Insert C
The School District to which you are applying prohibits discrimination based on race, color, religion, creed,
national origin, sex, marital status, age, pregnancy, or the presence of a disability, or any other basis
prohibited by law. This district is an equal opportunity employer, supports the spirit, policies, and practices
of affirmative action, and has implemented program to address the diversity of its workforce.
Your response to the following questions will assist the District in accurately reporting their employment
practices to state and federal agencies and complying with their affirmative action plan. Providing this
information is strictly voluntary and it shall be maintained as confidential. The completed data form will be
separated from other application materials and will not be reviewed by or available to those involved in the
hiring process. The data form will be kept separate from other records relating to applicants and date on
protected status shall not be recorded on any record that is kept in the applicant's pre-employment file.
Print Name:
Last
First
Sex:
Male
Disabled:
No
Mi.
Female
Aged (40 and above)
Yes - if yes, and you need assistance during the
application process, please contact Human
Resources.
I consider myself a member of the following ethnic group:
Asian or Pacific Islander
Black
Caucasian
Hispanic American
Native American Indian/Alaskan Native*
*If you have identified yourself as Native American Indian/Alaskan Native, please answer the
following questions:
I am affiliated with the
Tribe.
I am an enrolled member of this tribe:
Yes
No
Other (please specify)
DISABLED AND VIETNAM-ERA AFFIRMATIVE ACTION PROGRAM
A. Veteran: I am a Veteran of the United States Armed Services.
Yes
No
B. Vietnam-Era Veteran: The term "Vietnam-Era Veteran" means a person who, 1) served on active
duty for a period of more ant 180 days, any part of which occurred during August 5, 1964 through
May 7, 1975 and was discharged or released therefrom with other than a dishonorable discharge,
or 2) was discharged or released from active duty for a service-connected disability, if any part of
such active duty was performed during the Vietnam Era.
Yes
No
I meet the definition provided for "Vietnam-Era Veteran."
C. Disabled Veteran: The term "Disabled Veteran" means a person entitled to disability
compensation under laws administered by the Veterans' Administration for a disability rated at 30
percent or more, or a person whose discharge or release from active duty was for a disability
incurred or aggravated in the line of duty.
Yes
No
I meet the definition provided for "Disabled Veteran."
How did you learn about our School District or this position?
Walk in
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Referred by:
Friend
Other (Specify)
Other ______________________