GROESBECK INDEPENDENT SCHOOL DISTRICT

GROESBECK INDEPENDENT SCHOOL DISTRICT
P. O. BOX 559, GROESBECK, TEXAS 76642-0559
Phone Number: 254-729-4100
FAX Number: 254-729-2391
EMPLOYMENT APPLICATION FOR SUBSTITUTE PERSONNEL
We consider applicants for all positions without regard to race, color, national origin, age, religion, sex, marital status, veteran
or military status, the presence of any medical conditions, disability, or any other legally protected status.
An Equal Opportunity Employer
Personal Data
Date of application:______________________
Social Security Number:______________________
Name __________________________________________________________________________________
Last
First
Middle Initial
Current Address ____________________________________________________________________
Street/Box
____________________________________________________________________
City
State
Zip Code
Other address where you may be reached:______________________________________________________
Home phone ________________________________ Cell phone ___________________________________
Other name that may appear on records ________________________________________________________
(Used only for reference checks)
Position Data
List the position(s) for which you are applying
Type of employment:  Full-time  Part-time  Summer only
Date you can begin work
Have you been employed by Groesbeck ISD in the past?  Yes  No
Education Training
If you answered yes, provide dates of employment
Check the highest level of education attained:
 Not a high school graduate (Circle Last Grade Completed) 1 2 3 4 5 6 7 8 9 10 11 12
 High school graduate
 GED
 Less than two years of college
Two or more years of college
 Bachelor’s Degree
Master’s Degree
 Other training or education_________________________
Licenses and certificates held_________________________________________________________
Name and Location of
Schools Attended
Course of Study
and Major/Minor
Diploma, degree, Certificate,
or License Held
Year
Graduated
(College Only)
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EMPLOYMENT APPLICATION FOR SUBSTITUTE PERSONNEL
Special Skills
Working Experience
Please provide a complete list of all positions you have held in the past 10 years. List the most recent first.
Attach additional sheets if necessary (bus driver applicants, see addendum). Attach resume if available
Position/Title
Dates Employed
Reason for Leaving
Employer and Location
List specific skills and any machines or equipment you can operate. Include typing speed and
number of years of experience.
1.
2.
3.
4.
5.
6.
Do you have a relative who serves on the Groesbeck ISD Board of Trustee?
General Information
 Yes  No If yes, give the name of the relative and relationship:__________________________
Have you ever been convicted of, pled guilty or no contest (nolo contendre) to, or received probation,
suspension, or deferred adjudication for a felony or any offense involving moral turpitude (including, but not
limited to theft, rape, murder, swindling, and indecency with a minor)?  Yes  No
If yes, please state where, when and the nature of the offense; indicate whether the charges were dismissed as
a condition of probation, suspension, or deferred
adjudication:______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
(Conviction of a felony is not an automatic bar to employment. The district will consider the nature,
date and relationship between the offense and the position for which you are applying.)
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EMPLOYMENT APPLICATION FOR SUBSTITUTE PERSONNEL
References
Please provide a complete list of all positions you have held in the past 10 years. List the most recent first.
Attach additional sheets if necessary (bus driver applicants, see addendum). Attach resume if available
Position/Title
Dates Employed
Reason for Leaving
Employer and Location
Verification
I hereby affirm that all information provided in this application is true and accurate to the best of my
knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact
may be grounds for rejection of my application or dismissal from subsequent employment.
I authorize the references listed on the previous page to give you any and all information concerning
my previous employment and any pertinent information they may have, personal or otherwise, and
release all such parties from liability for any damage that may result from furnishing the same to
you.
I understand that the district is authorized by Texas Education Code §22.083 to obtain criminal
history record information on applicants the district intends to employ.
______________________________ _______________
Signature
Date
This application becomes the property of the district. The district reserves the right to accept or
reject it.
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ADDENDUM FOR SCHOOL BUS DRIVER APPLICANTS
Any person who applies to be a bus driver must provide the following information at the time of application.
NOTE: Bus drivers must pass a physical examination and a drug test.
An Equal Opportunity Employer
Name:____________________________________ Phone Number:__________________________
# of Hours Available for Work:_______ Driver’s License Number:_________________Type:_____
Do you have a Texas School Bus Driver Training Certificate? . . . . . . . . . . . . . .  Yes  No
If you answered yes, explain:_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Are there any criminal charges or proceedings pending against you? . . . . . . . . .  Yes  No
Personal Data
If you answered yes, explain:_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Have you ever been convicted of, plead guilty or no contest (nolo contender) to, or received
probation, suspension, or deferred adjudication for any traffic violation? . . . . . .  Yes  No
If you answered yes, explain:_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
In the past two years, have you failed an employer’s alcohol or drug test? . . . . . .  Yes  No
If you answered yes, explain:_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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ADDENDUM FOR SCHOOL BUS DRIVER APPLICANTS (Continued)
Working Experience
Please provide a complete list of all positions you have held in the past 10 years. List the most recent first.
Attach additional sheets if necessary (bus driver applicants, see addendum). Attach resume if available
Employer Address
Dates
Kind of Work
Reason for Leaving
Employed
and Phone
Verification
I hereby affirm that all information provided in this application is true and accurate to the best of my
knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact
may be grounds for rejection of my application or dismissal from subsequent employment.
I understand that the district is required by federal regulations to obtain alcohol and drug testing
results from previous employers for two years prior to this application and required by Texas
Education Code §22.084 and Transportation Code §521.022 (f) to conduct a criminal history record
check.
Furthermore, I authorize the information I have provided to be used; previous employers to be
contacted for investigative purposes; and release all parties from any liability for damage that may
result from furnishing information to you.
______________________________ _______________
Signature
Date
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GROESBECK INDEPENDENT SCHOOL DISTRICT
P.O. BOX 559 / 1202 N. ELLIS
GROESBECK, TEXAS 76642-0559
Dr. Harold D. Ramm
Superintendent of Schools
Phone Number 254-729-4100
Fax Number
254-729-2391
This letter provides notice of reasonable assurance of continued employment with the district
when each school term resumes after a school break.
By virtue of this notice, please
understand that you may not be eligible for unemployment compensation benefits drawn on
school district wages during any scheduled school breaks including, but not limited to, the
summer, Christmas, and spring breaks. This assurance is contingent on continued school
operations and will not apply in the event of any disruption that is beyond the control of the
district (i.e., lack of school funding, natural disasters, court order, public insurrections, war, etc.).
Nothing contained herein constitutes an employment contract. Your continued employment is
on an at-will basis. At-will employers may terminate employees at any time for any reason or for
no reason, except for legally impermissible reasons. At-will employees are free to resign at any
time for any reason or for no reason.
Your services on behalf of the children of the district are appreciated, and we hope that you will
be able to continue your association with the district.
Sincerely,
Dr. Harold D. Ramm, Superintendent
Name (Print)
Date
Signature
Social Security
Address
Primary Phone
City
Zip
Secondary Phone (if applicable)
Level of highest level of education attained: (check all that apply)
___ Not high school graduate (last grade completed____)
___ High school graduate
___ GED
___ Less than 2 years of college
___ 2 or more years of college
___ Bachelor’s Degree
___ Master’s Degree
___Certified Teacher
I would like to sub at the following: (check all that apply) ___HOW ___EWIS ___GMS ___GHS
___Office
___Cafeteria
___Custodian
___Transportation
Other:_____________________
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___Maintenance
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NOTICE TO NEW EMPLOYEES
Groesbeck Independent School District has workers’ compensation insurance coverage from the Texas
Association of School Boards Workers’ Compensation Self-Insurance Fund to protect you. You can get
more information about your workers’ compensation rights from any office of the Texas Workers
Compensation Commission or by calling 1-800-252-7031.
You may elect to retain your common law right of action if, no later than five days after beginning
employment, you notify Groesbeck Independent School District in writing that you wish to retain your
common law right to recover damages for personal injury. If you elect your common law right of action,
you cannot obtain workers’ compensation income or medical benefits if you are injured.
AVISO A NUEVOS EMPLEADOS
Groesbeck Distrito de la Escuela Independiente esta curierto por aseguranza de compensacion al
trabajador atraves de Tejas Asociacio de obreros de las Regentes de la Escuela Compensacion que SelfInsurance Consolida para su proteccion. Usted puede obtener informacion adicional sobre sus derechos
de compensacion al trabajador de cualquier oficina de la Comision de Compensacion de Trabajodores de
Tejas, o peude llamar al 1-800-252-7031.
Usted peude elegir retener su derecho a acciones bajo la ley comun, si, no mastarde de cinco dias despues
de comenzar empleo, usted notifica a Groesbeck distrito de la Escuela Independente por escrito que usted
desea retener su derecho bajo la ley comun para recobrar danos por lesions personales. Si usted elige su
derecho de accion por la ley comun, usted no puede obtener ingreso de compensacion al trabajador o
beneficios mediocos si es usted lesionsado/a.
_____________________________________________
Signature
Date
PLEASE SIGN AND RETURN TO PERSONNEL OFFICE
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ALCOHOL AND DRUG-FREE ENVIRONMENT
Groesbeck ISD is committed to maintaining a drug-free environment and will not tolerate the use of illegal drugs in
the workplace. Employees who use or are under the influence of alcohol or illegal drugs as defined by the Texas
Controlled Substances Act during working hours may be dismissed. The district’s policy on drug abuse and drugfree schools follows:
1.
Any controlled substance or dangerous drug as defined by law, including but not limited to marijuana, any
narcotic drug, hallucinogen, stimulant, depressant, amphetamine, or barbiturate.
2. Alcohol or any alcoholic beverage.
3. Any abusable glue, aerosol paint, or any other chemical substance for inhalation.
4. Any other intoxicant, or mood-changing, mind altering, or behavior-altering drugs.
An employee need not be legally intoxicated to be considered “under the influence” of a controlled substance.
An employee who uses a drug authorized by a licensed physician through a prescription specifically for that
employee’s use; shall not be considered to have violated this policy.
DRUG-FREE WORKPLACE REQUIREMENTS
The District prohibits the unlawful manufacture, distribution, dispensation, possession, or use of a controlled
substance, illicit drug and alcohol as those terms are defined in state and federal law, in the workplace, on school
premises or as part of any of the District’s activities. 41 U.S.C. 702 (a)(l)(A): 28 TAC 169.2
Employees who violate this prohibition shall be subject to disciplinary sanctions. Such sanctions may include
referral to drug and alcohol counseling or rehabilitation programs or employee assistance programs, termination
from employment with the District, and referral to appropriate law enforcement officials for prosecution.
Information on available rehabilitation or employee assistance programs and contacts shall be posted throughout
the workplace. 41 U.S.C. 702 (a)(l)(A): 28 TAC 169.2
Compliance with these requirements and prohibitions is mandatory and is a condition of employment. As a further
condition of employment, an employee shall notify the Superintendent of any criminal drug statutes conviction the
employee incurs for a violation in a workplace no later than five days after such conviction. 41 U.S.C. 702
(a)(l)(D)
Within 30 calendar days of the Superintendent’s receiving notice from any source of a conviction for any drug
statute violation occurring in the workplace, the Superintendent or designee shall either (1) take appropriate
personnel action against the employee, up to and including termination of employment or (2) require the employee
to participate satisfactorily in a drug and alcohol abuse assistance or rehabilitation program approved for such
purposes by a federal, state, or local health agency, law enforcement agency, or other appropriate agency. The cost
of any such program shall be borne by the employee. 41 U.S.C. 702 (a)(l)(B), 703
(This notice complies with notice requirements imposed by the federal Drug-Free Workplace Act [20 U.S.D. 3471,
1221e-3 (a) and 34 CFR 85.630]; notice requirements imposed by the Texas Workers’ Compensation Commission
rules at 28 TAC 169.2)
I have received a copy or have viewed of the alcohol and drug policy adopted and used by the Groesbeck
Independent School District from the district’s website: www.groesbeck.k12.tx.us.
Signature
Date
PLEASE SIGN AND RETURN TO THE PERSONNEL OFFICE
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CRIMINAL HISTORY RECORD INFORMATION REQUEST
Confidential
The Groesbeck Independent School District is required by Texas Education Code Chapter
22, Subchapter C to review the criminal history of applicants, employees, independent
contractors, student teachers, and certain volunteers. The information requested below is
necessary to obtain criminal history record information.
Please Print:
Name______________________________________________________________________
Last
First
Middle Name
Social Security Number_______________________ Date of Birth_____________________
Driver’s License_______________________________________
State
Number
Mailing Address ______________________________________________
Street
_______________________________________________
City
State
Zip
Sex:  Male  Female
Ethnicity:  Black
 White/Other
I understand that the information I am providing about age, sex, and ethnicity will not be
used to determine eligibility for employment but will be used solely for the purpose of
obtaining criminal history record information.
_____________________________________
Signature
__________________________
Date
This form will be removed from the application and filed separately in the HR office.
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DPS Computerized Criminal History (CCH) Verification
(AGENCY COPY)
I,
, have been notified that a Computerized Criminal
APPLICANT or EMPLOYEE NAME (Please Print)
History (CCH) verification check will be performed by accessing the Texas Department of
Public Safety Secure Website and will be based on name and DOB information I supply.
Because the name based information is not an exact search and only fingerprint record searches
represent true identification to criminal history, the organization (as listed below) conducting the
criminal history check is not allowed to discuss any information obtained using this method,
therefore the agency may offer the opportunity to have a fingerprint search performed to clear
any misidentification based on the name search, if the search provides a criminal report I know
could not be mine.
For the fingerprinting process I will be required to submit a full and complete set of my
fingerprints for analysis through the Texas Department of Public Safety AFIS (automated
fingerprint identification system). I have been made aware that in order to complete this process
I must have the correct fingerprinting (FAST) form from this agency, make an online
appointment, submit a full and complete set of my fingerprints, and a fee will be prepaid by the
agency to the fingerprinting services company, L1 Enrollment Services.
Once this process is completed and the agency receives the data from DPS, the information on
my fingerprint criminal history record may be discussed with me.
(This copy must remain on file by your agency. Required for future DPS Audits)
F O R O F FI C E US E O NL Y
Signature of Applicant or Employee
Please:
Check and Initial each Applicable Space
/
/
CCH Report Printed:
Date
YES___ NO___
Groesbeck I.S.D.
Agency Name (Please Print)
Purpose of CCH: ___ Substitute
___ Service & Support
___ Professional
Other:_____________________
Agency Representative Name (Please Print)
Signature of Agency Representative
/
_____Initial
/
Date
Hired___ Not Hired___
_____Initial
Date Printed:___/___/___
_____Initial
Destroyed Date:___/___/___
_____Initial
Retain in your files
ADB/Verification
08/2009
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Admin. Asst. / Exec. Secretary
Battrick, Teresa or Rand, Tammy
1202 N. Ellis Street
Groesbeck I.S.D.
Groesbeck
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Texas
76642
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Groesbeck I.S.D., 1202 N. Ellis, Groesbeck, Texas 76642
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