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
CERTIFICATED PERSONNEL APPLICATION FORM
PLEASE PRINT THIS SECTION
Date of Application:
Name
Date Available
SS #
t
(Last)
(First)
Present Address
Permanent Address
(Middle)
-
-
(Street)
(City)
(State)
(Zip)
(Street)
(City)
(State)
(Zip)
Home Phone (_____)
i
Work Phone (______)
E-Mail Address:
Present Employment Status
JOB PREFERENCE
POSITIONS FOR WHICH YOU ARE APPLYING:
Preschool
Elementary
Middle School
High School
Administration
Librarian
Special Education
Specialist
Other: ____________________
Please specify if applying for a posted vacancy:
Do you hold a current endorsement in the area(s) marked?
No
Yes
ELEMENTARY - Prioritize the grade level/subjects you are prepared to teach with 1 being your first choice.
___ K ___ 1st ___ 2nd ___ 3rd ___ 4th ___ 5th l___ 6th ___ Spec Ed ___ Elem Music ___ Elem PE
________________________________________________________________________________________
SECONDARY - Prioritize the subjects you are prepared to teach with 1 being your first choice.
___ Language Arts
____ Mathematics
____ Science
____ Social Studies/History
___ Music/Band/Choir
____ Foreign Language
____ Special Ed
____ Technology
l
___
Business Ed
____ Family/Consumer Ed
____ Industrial Arts
____ Other:_______
CERTIFICATION: List below teaching, administrative and special certificates held.
(You must hold a valid teaching certificate endorsed in the areas that you are applying for.)
Type of Certificate
Date Issued
Expiration Date
e
PLEASE PROVIDE A COPY OF ALL CERTIFICATES LISTED
State
EDUCATION/TRAINING
Name of School & Location
Year Graduated
GPA
High School
College or University
Diploma/Degree
Major/Minor
College or University
Diploma/Degree
Major/Minor
College or University
Diploma/Degree
Major/Minor
PLEASE PROVIDE COPIES OF TRANSCRIPTS FOR ALL COLLEGES LISTED
First Aid Training (Levels)
Card Expiration Date
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?
No
Yes #
No
No
Yes #
Yes #
Extracurricular activities for which you are qualified and willing to be considered for a position:
Class Advisor
Band
Annual
Gymnastics
Knowledge Bowl
Basketball
Volleyball
ASB
Other:
Drama
Football
Cheerleaders
Track
CERTIFICATED EXPERIENCE (including substitute employment) List most recent experience first. (Include
student teaching/practicum only if you are a beginning teacher.)
Dates
From/To
District
Location
City/State
Subjects Taught or
Position Held
Reason for Leaving
Provide the following information about your immediate supervisor(s) for the last five (5) years of employment.
Dates
From/To
Supervisor Name/Title
District/Location
Telephone Number(s) Include Area Code
OTHER EMPLOYMENT EXPERIENCE - List other work experience (including military):
Approx.
Employer's Name, Address, Zip,
Supervisor/
Position Held
Reason Left
Dates
Phone Number
Title
From:
Name
Address
To:
Phone
From:
Name
l
To:
Address l
Phone
From:
Name
Address
To:
Phone
REFERENCES - List additional professional references (other than immediate supervisors already provided) who
have firsthand knowledge of your personal and professional competencies.
Name
Address
Phone
Official Position
APPLICATION INFORMATION
1.
Candidates are required to submit the following:
A.
Completed district application form and supplemental Inserts A and B. Insert C is optional.
B.
Resume and Letter of Introduction
C.
D.
E.
F.
2.
3.
4.
5.
6.
College placement file
Copy of Certificates held
Any other information that the candidate feels worthwhile for consideration.
Transcripts: Unofficial transcripts should be submitted as part of the application. Official
transcripts will be required of all appointed candidates
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.
Finalists will be scheduled for interviews. Citizenship: Pursuant to federal law, candidates must provide
evidence of citizenship and verification of identification if selected for interview.
Finalists' references will be contacted.
The superintendent will issue an offer to the candidate selected for the position. If the person accepts, he
or she will be recommended by the superintendent to the Board of Directors. All employees will be
required to have fingerprint clearance from Washington State Patrol and the FBI at their own expense.
Fingerprinting is available at the District Office.
Following board approval, the superintendent will issue an offer to the candidate of his/ her employment
and issue a contract or other employment document.
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.
ONLY THOSE SELECTED FOR AN INTERVIEW WILL BE CONTACTED.
EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
Cape
Flattery
No. 401with
is an
equal and
opportuni
ty employer
and employs
individuals
withoutonregard
The
Cape
FlatterySchool
School District
District complies
all federal
state laws
and regulations
and does
not discriminate
the to
basis
race, ethnicity,
nationalorigin,
origin, age,
sex, sexual
orientation,
religion,
age, disability andThis
/or veteran
This
holds
race,ofcreed,
color, national
sex, marital
status,
or handicap/disability.
policy status.
complies
with
all true
for
all district state
employment
and opportunities.
Inquiries regarding
compliance
and compliance
/or grievanceand/or
procedures
should procedures
be directed
applicable
and federal
rules and regulations.
Inquiries
regarding
grievance
to
the be
school
district's
Titleschool
IX compliance
and/ 281.640
or SectionOfficer
504 /ADA
coordinator,
C/O Cape
Flattery School
District,
may
directed
to the
districtscoordinator
Title IX/RCW
and/or
the Section
504 Coordinator,
P.O.
Box
109,
Sekiu,
WA
98381.
(360)
963-2329.
Box 109, Sekiu, WA 98381
CHECKLIST - Please use the following checklist as your guide to fulfilling the requirements for a
complete application file.
Completed District Application Form (including signature)
Required:
Copies of Washington State Teaching Certificate(s)
General Cover Letter
Current Resume
Copies of College Transcripts
College Placement File en route
Optional:
Insert A- Washington State Sexual Misconduct Disclosure Release
Insert B - Applicant Disclosure Statement
Insert C - Optional Confidential Information Form
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.
________________________________
Applicant 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 ________________________________
PLEASE PROVIDE ADEQUATE POSTAGE
Date ____________
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.
*____________________________________
*______________________________
Applicant's Signature
Date
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
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 Murder
First or Second Degree Extortion
First or Second Degree Robbery
Felony Indecent Exposure
Unlawful Imprisonment
First or Second Degree Criminal
Mistreatment
Promoting Pornography
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.
Aged (40 and above)
Female
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:
Black
Asian or Pacific Islander
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."
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