Ferndale School District Application !

Transcription

Ferndale School District Application!
!
Thank you for your interest in working for our school district. This application is good for most nonteaching posted positions, including Para-Educator, Custodial, Clerical, Food Service, Bus Driver,
Translators, etc. The school district accepts applications for regular, continuing or temporary positions
only when job openings are available.
!
!
!"#$%#&'()#*&&+,&-(.&/0%1&)(&2#&$&%.2%)0).)#&03&(.4&50%)406)&-(.&7.%)&,0""&(.)&)1#&
!"#$%&%"%'()**+&,-%&./(*-,0'%&$35&,(""(/&)1#&(.)"03#5&03%)4.6)0(3%&0)&6(3)$03%8!
!
APPLYING FOR A REGULAR or TEMPORARY POSITION:!
!
Complete the attached classified application if you are interested in applying for a full-time or parttime regular or temporary position. This application must be accompanied by a letter of interest
addressed to the person named in the job posting and an up-to-date resume. If you are hired in
any capacity there will be additional paperwork, including fingerprint background check,
payroll paperwork, etc. !
!
!
!
All application paperwork must be received at the district office located at 6041 Vista Dr.
Ferndale WA. 98248. A copy will be kept on file at the district office for one year. Applications will
be copied and forwarded to the appropriate department for consideration. You are encouraged to
follow up with the appropriate department(s) regarding the status of your application.
!
"#!$%&!'()*!(+$!,&*-./%+-!01*(-*!2%+.(2.!3*44/!3/15%4*6!71(--/#/*8!9&5(+!:*-%&42*-!
!
;<=>?!<@<ABC>C!%4!D*44/ED/15%4*F#*4+8(1*-8E%4D!
!
FERNDALE SCHOOL DISTRICT #502
P.O. Box 698, 6041 Vista Drive
Ferndale, WA 98248
ATTN: Classified Personnel
Position Applying For _____________________
Please check all that apply!
Full - Time
Bus Driver
Custodial Maint.
Grounds Maint.
Food Service
(360) 383-9232
Yes / No
Part-Time
Yes / No
Substitute / On-Call
Yes / No
Secretary
Para-Educator
PERSONAL DATA
Name
Date of Application
Last
First
Middle
Address
Home Phone
(
)
Alternate Phone
(
)
Street
City
State
Zip
Social Security #
Email:
--
--
EXPERIENCE WITH COMMUNITY AND YOUTH GROUPS
REFERENCES
List references, excluding relatives, who may be contacted
Name
Equal Opportunity Employer
Street Address, City, State, Zip
Telephone
Occupation
Page 1
EXPERIENCE
List your most recent employment first. If additional space is needed, attach a separate sheet of paper.
May we contact the employers listed below?
YES / NO
If not, indicate which one(s) you do not wish us to contact.
Month & Year
From
To
Employer / Address
Position
Held/Duties
Reason for
Leaving
Supervisor(s) Name /
Phone No.
Page 2
EDUCATION
Name of High School
Location
Did you Graduate?
Yes
G.P.A.
No
College or University
Location
Dates
Degree
Major
Other Education
Location
Dates
Degree
Major
OTHER
Are you able to perform the duties and tasks of the position for which you are applying with or
without reasonable accommodation or assistance?
With accommodation or
assistance
Without
accommodation or
If accommodation or assistance would be required, please explain how you would perform the
duties and tasks, and with what accommodation.
During the past seven years, have you been convicted of any crime or been released
from prison? _______ If yes, please describe fully. An affirmative answer does not
necessarily disqualify you from employment.
Page 3
CUSTODIAL / MAINTENANCE SKILLS
Skill
YES
NO
Degree of Proficiency
Plumbing
Electrical
Control Technician
Carpentry
Custodial
OTHER
List the area(s) for which you have a journeyman rating:
GROUNDS MAINTENANCE SKILLS
Skill
YES
NO
Lawn Care
Pruning
Control Spraying
Landscaping
Equipment Maintenance
OTHER
List the area(s) for which you have a journeyman rating:
PARA - EDUCATOR SKILLS / ACCOMPLISHMENTS
Skill
YES
State Core Competency Requirements
met? (test or associates degree)
AA Degree Earned?
Experience working with special
needs/troubled youth?
Training in De-Escalation/Anger
Management?
Academic mentoring/tutoring (specify
subject and levels)?
Experience supervising youth in a
classroom or playground activities?
NO
Degree of Proficiency / Experience
OTHER
Page 4
LICENSES / CERTIFICATES
Type of License / Certificate
YES
NO
Expiration
Date
Endorsements
Washington State School Bus Drivers' Certificate
Specify date of most recent bus driver in-service
course
DATE ___________ LOCATION __________________
List any moving violations in the last three years
Have you taken the Bellingham Vocational
Technical Institute's Bus Driver course?
LOCATION
_________________
Valid First Aid Card
Washington State Driver's License
Food Handlers' Permit
OTHER
OFFICE / CLERICAL / ACCOUNTING SKILLS
Skill
YES
NO
Keyboard Speed
w.p.m. ____________
Shorthand / Transcription
&RPSXWHUVDQG%UDQG0DF3&«
Word processor (and Brand)
Database and Spreadsheets (and Brand)
Other Software Used (please specify)
10 Key (by sight or touch?)
Sight
Touch
Fax Machine
Copy Machine
Multi-Line Telephones
Customer Service
Are you more comfortable in slow or
fast paced environments? Do you work
better alone or on a team? Supervised
or Unsupervised?
OTHER
Page 5
PERSONAL GOALS
In the spaces below, please state why you desire employment with the Ferndale School District
and any other skills/qualifications not listed above that you bring to this position.
NOTICE
Pursuant to Chapter 486, Laws of 1987, an inquiry will be made to the Washington State Patrol or a Federal law
enforcement agency to determine whether a perspective employee has been (1)(a) convicted of any offense against
persons; (b) found in any dependency action under RCW 13.34.030; (c) to have sexually assaulted or exploited any
minor or to have physically abused any minor; or (d) found in any disciplinary board final decision. Any response
received from the Washington State Patrol or a Federal law enforcement agency pursuant to such inquiry will be made
available to the individual.
I certify that the information listed on the application is accurate and true. Further, I understand
the district will request a background check for perspective employees through the Washington
State Patrol and FBI pursuant to Chapter 486, Laws of 1987.
Date
Signature
Ferndale School District complies with all state and federal rules and regulations and does not discriminate on the
basis of sex, race, creed, religion, color, national origin, age, veteran or military status, sexual orientation, gender
expression or identity, disability, or the use of a trained guide dog or service animal and provides equal access to the
Boy Scouts and other designated youth groups. This holds true for all district employment opportunities.
Page 6
Ferndale School District No. 502
Optional Confidential EEO Data Form
The Ferndale School District complies with all state and federal rules and regulations and
does not discriminate on the basis of sex, race, creed, religion, color, national origin, age, veteran
or military status, sexual orientation, gender expression or identity, disability, or the use of a
trained guide dog or service animal and provides equal access to the Boy Scouts and other
designated youth groups except as may be necessary to meet a bona fide occupational
qualification. The District is an equal opportunity employer, supports the spirit, policies, and
practices of affirmative action, and has implemented programs to address the diversity of its
workforce.
A response to the following questions will assist the District in accurately reporting its
employment practices to state and federal agencies and complying with the District's affirmative
action plan. Providing this information is strictly voluntary and it shall be maintained as
confidential. The completed data form will be kept separate from other personnel records, and
data on protected status shall not be recorded on any record that is kept in an employee or
applicant's personnel file.
Date: ____________________________
Name: _______________________________________________________________________
Position Applied For: __________________________________________________________
Sex:
Female
Male
Race/Ethnicity: The current legal definition of each racial/ethnic group is provided below.

American Indian or Alaskan Native: persons having origins in any of the original peoples
of North, Central, or South America and who maintain tribal affiliation or community
attachment.

Asian or Pacific Islander: persons having origins in any of the original peoples of the Far
East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands.

Black or African-American (not of Hispanic origin): persons having origins in any of the
Black racial groups of Africa.

Hispanic or Latino: persons of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, regardless of race.

White (not of Hispanic origin): persons having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
February, 14
FERNDALE SCHOOL DI STRI CT NO.502
Ferndale, Washington
AUTHORI ZATI ON TO CHECK WORK HI STORY
I authorize Ferndale School District to check my references and to investigate any information provided
in my application for employment. I further authorize my past employers or anyone with information
about my work history, education or qualifications to provide such information to Ferndale School
District in response to their inquiry. I agree to hold harmless from any liability (suit, claim or other action)
anyone supplying such information to Ferndale School District.
Should I become employed by Ferndale School District and at some future time leave said employment,
my signature below further authorizes Ferndale School District to release information regarding my
performance to any potential future employer.
Signed:
(Applicant Name Printed or Typed)
Date
Ferndale School District No. 502
PO Box 698
Ferndale, WA 98248
(360) 383-9206 Fax (360) 383-9201
PRE-EMPLOYMENT BACKGROUND QUESTIONNAIRE
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 Ferndale School District.
ALL REQUIRED DOCUMENTATION REQUESTED BELOW MUST ACCOMPANY THIS FORM. ALL QUESTIONS MUST
BE ANSWERED. IF ADDITIONAL SPACE IS NEEDED, ATTACH A SEPARATE SHEET OF PAPER.
SECTION I – PERSONAL INFORMATION (please print or type)
1.
NAME:
2.
ADDRESS:
(Complete mailing address)
3.
TELEPHONE:
4.
Please list all former names (a) you have used when working for another employer, or (b) by which you are known to
reference. If you have more than three, list them on a separate sheet of paper.
(
)
Business
(
)
Home
SECTION II – PROFESSIONAL FITNESS
(If you answer "yes" to questions 1 through 4, on a separate sheet of paper, give a complete explanation, including duties,
circumstances, and any supporting documentation.
Yes
No
1. Have you ever been dismissed, discharged or fired from any employment?
2. Have you ever resigned from or otherwise left any employment while allegations of misconduct on your part were
pending or under investigation?
3. Have you ever been disciplined by a past or present employer because of allegations of misconduct?
4. Are you currently or have you ever been the subject of any investigation or inquiry by an employer because of
allegations of misconduct on your part?
SECTION III – CRIMINAL HISTORY
Yes
No
1.
2.
Have you ever been convicted of any crime? (Note: For the purpose of this question "convicted" includes (a) all
instances in which a plea of guilty or nolo contendere is the basis of conviction, and (b) all proceeding in which
a sentence has been suspended or deferred.) You need not list traffic violations for which a fine or forfeiture of
less than $150.00 was imposed.
a.
Do you currently have any outstanding criminal charges or warrants of arrest pending against you in
Washington?
b.
Do you currently have any outstanding criminal charges or warrants of arrest pending against you in
any other state, province, territory, and/or country?
If you answered "yes" to questions l or 2 of Section Ill, please provide the following:
a.
b.
c.
d
e.
f.
g.
A detailed statement including what occurred, the nature of the offense, charge or warrant;
The name and address of the arresting agency;
The date of the arrest;
The final disposition, if any;
If a court was involved, the name and address of the court;
The complete arrest report and sentence and judgment; and
A complete driving abstract for five years if the arrest was driving related.
Yes
No
3.
Are you presently under in investigation in any jurisdiction for possible criminal charges? If your answer is
"yes", identify agency and location (street address, city, and state).
A “yes” answer to questions 1 through 3 above will not necessarily bar you from employment.
SECTION IV - FITNESS
Yes
No
1.
Are you able to perform the essential functions of the certificated/classified position(s) for which you have
applied with or without reasonable accommodation?
2.
Do you currently use illegal drugs?
3.
Have you used illegal drugs in the last year? If your answer is “yes”, explain on a separate sheet of paper.
4.
Have you ever been found in any dependency or domestic relations matter to have sexually assaulted or exploited
any minor?
5.
Have you ever been found in any dependency or domestic relations matter to have physically abused any person?
If you answered "yes" to questions 3 or 4, attach copies of any court orders entered in the above proceeding.
DECLARATION
I,
certify (or declare) under the penalty of perjury under
the laws of the State of Washington that the foregoing and all information included in the
application is true and correct.
If the information provided or answer(s) to any question on the application or the eEmployment Background Questionnaire change prior to my being hired, I understand at I must
immediately notify the Ferndale School District.
I understand I must answer this application truthfully and completely. Any falsification or liberate misrepresentation, including omission of a material fact, in completion of this
application can be grounds for denial of employment or continued employment.
Signature
Date
City /State
!--.(2!"3'4(#2.0#5&%'
!
-5&#5!"3'30'&2$'678678976'
!
2:(.4'!"4'!45.3'!/5#%'(")0&;!3(0"'!23
!
!
"#$%&'!()*!+'!,-!.+!&/01!23$.&4!3.&56!78!.1&!/#$%&'!3$!()*!.+!/#9!3.&5:!&;<2/3#!3#!.1&!/'&/!<'+=34&4:!3#430/.3#>!.1&!
01/'>&!+'!83#43#>:!.1&!4/.&:!/#4!.1&!0+?'.@$A!3#=+2=&46!!B3.13#!.1&!2/$.!$&=&#!9&/'$C!
!
D6!
!
!
!
!
!
K6!
E/=&!9+?!F&&#!0+#=30.&4!+8!/#9!0'35&$!/>/3#$.!01324'&#!+'!+.1&'!<&'$+#$:!/$!8+22+%$C!!/>>'/=/.&4!5?'4&'G!83'$.!+'!$&0+#4!4&>'&&!5?'4&'G!
83'$.!+'!$&0+#4!4&>'&&!H34#/<<3#>G!83'$.:!$&0+#4:!+'!.13'4!4&>'&&!/$$/?2.G!83'$.:!$&0+#4:!+'!.13'4!4&>'&&!'/<&G!83'$.:!$&0+#4:!+'!.13'4!4&>'&&!
'/<&!+8!/!01324G!83'$.!+'!$&0+#4!4&>'&&!'+FF&'9G!83'$.!4&>'&&!/'$+#G!83'$.!4&>'&&!F?'>2/'9G!83'$.!+'!$&0+#4!4&>'&&!5/#$2/?>1.&'G!83'$.!+'!$&0+#4!
4&>'&&!&;.+'.3+#G!3#4&0&#.!23F&'.3&$G!3#0&$.G!=&130?2/'!1+53034&G!83'$.!4&>'&&!<'+5+.3#>!<'+$.3.?.3+#G!0+55?#30/.3+#!%3.1!/!53#+'G!?#2/%8?2!
35<'3$+#5&#.G!$35<2&!/$$/?2.G!$&;?/2!&;<2+3./.3+#!+8!53#+'$G!83'$.!+'!$&0+#4!4&>'&&!0'353#/2!53$.'&/.5&#.G!01324!/F?$&!+'!#&>2&0.!/$!4&83#&4!
3#!IJB!KL6MM6NKNG!83'$.!+'!$&0+#4!4&>'&&!0?$.+43/2!3#.&'8&'&#0&G!5/2303+?$!1/'/$$5&#.G!83'$.:!$&0+#4:!+'!.13'4!4&>'&&!01324!5+2&$./.3+#G!83'$.!
+'!$&0+#4!4&>'&&!$&;?/2!53$0+#4?0.!%3.1!/!53#+'G!</.'+#3O3#>!/!P?=&#32&!<'+$.3.?.&G!01324!/F/#4+#5&#.G!<'+5+.3#>!<+'#+>'/<19G!$&223#>!
+'!43$.'3F?.3#>!&'+.30!5/.&'3/2!.+!/!53#+'G!0?$.+43/2!/$$/?2.G!=3+2/.3+#!+8!01324!/F?$&!'&$.'/3#3#>!+'4&'G!01324!F?93#>!+'!$&223#>G!<'+$.3.?.3+#Q
!
!
!"#$%&''' '
'''''''''''''()'*%#+'%,-.!("'/%.0$1'
!
!
!
!
E/=&!9+?!F&&#!0+#=30.&4!+8!0'35&$!'&2/.3#>!.+!.1&!83#/#03/2!&;<2+3./.3+#!38!.1&!=30.35!%/$!/!=?2#&'/F2&!/4?2.:!/$!8+22+%$C!83'$.:!$&0+#4:!+'!
.13'4!4&>'&&!&;.+'.3+#G!83'$.:!$&0+#4:!+'!.13'4!4&>'&&!.1&8.G!83'$.!+'!$&0+#4R4&>'&&!'+FF&'9G!8+'>&'9Q!
!
!"#$%&''' '
'''''''''''''()'*%#+'%,-.!("'/%.0$1'
!
!
!
!
!
!
!
!
!
S6!! E/=&!9+?!F&&#!8+?#4!3#!/#9!4&<&#4&#09!/0.3+#!?#4&'!IJB!DS6SM6NSN@KA@FA!.+!1/=&!$&;?/229!/$$/?2.&4!+'!&;<2+3.&4!/#9!53#+'!+'!.+!1/=&!
<19$30/229!/F?$&4!/#9!53#+'Q!
!
!
!
!"#$%&''' '
'''''''''''''()'*%#+'%,-.!("'/%.0$1'
!
!
!
!
!
!
!
!
!
M6!! E/=&!9+?!F&&#!8+?#4!3#!/#9!4+5&$.30!'&2/.3+#$!<'+0&&43#>!?#4&'!T3.2&!KL!IJB!.+!1/=&!$&;?/229!/F?$&4!+'!&;<2+3.&4!/#9!53#+'!+'!.+!1/=&!
<19$30/229!/F?$&4!/#9!53#+'Q!
!"#$%&''' '
'''''''''''''()'*%#+'%,-.!("'/%.0$1'
!
!
!
!
!
!
!
!
!
U6!! E/=&!9+?!F&&#!8+?#4!3#!/#9!43$03<23#/'9'F+/'4!83#/2!4&03$3+#!.+!1/=&!$&;?/229!+'!<19$30/229!/F?$&4!+'!&;<2+3.&4'/#9!53#+'!+'!
4&=&2+<5&#./229!43$/F2&4!<&'$+#!+'!.+!1/=&!/F?$&4'+'!83#/#03/229!&;<2+3.&4!/#9!=?2#&'/F2&!/4?2.Q!
!
!"#$%&''' '
'''''''''''''()'*%#+'%,-.!("'/%.0$1'
!
!
!
!
!
!
!
!
!
L6! E/=&!9+?!F&&#!8+?#4!3#!/#9!<'+.&0.3+#'<'+0&&43#>!?#4&'!01/<.&'!VM6S!!IJB:!.+!1/=&!/F?$&4!+'!83#/#03/229!&;<2+3.&4!/!=?2#&'/F2&!/4?2.Q!
!"#$%&''' '
'''''''''''''()'*%#+'%,-.!("'/%.0$1'
!
!
!
!
!
!
!
!
!
W?'$?/#.!.+!IJB!X"6VK6NYU:!7!0&'.389!?#4&'!<&#/2.9!+8!<&'P?'9!?#4&'!.1&!2/%$!+8!.1&!!
*./.&!+8!B/$13#>.+#!.1/.!.1&!8+'&>+3#>!3$!.'?&!/#4!0+''&0.6!
!
"<<230/#.!*3>#/.?'&C!!!
!
Z/.&C!!!
!
!
B3.#&$$C!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! W2/0&C!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!
"#$%&'()%*!!+,--.!
!
!
%/01232/24!+556738,256!
"#$%&#!
!
!
!
!!"#$%"&'()*((+,($-'")$+#.",+&()/!
'(')*+'+! !
9557!%46:3;4!<==-3;,821!
,$-./!
!
!
'(')*'01! !
!
.%..%#$&0)1$,-'")$+#.",+&()/!
!
>/1!?63:46!<==-3;,821!
!
,23&!!!
!
!
'(')*+'4! !
!2())%$#&34()$3($-'")$+#.",+&()/5
5
@,38248,8;4!<==-3;,821!
5$6&!!
!
!
'(')*+'0! !
!
3#6#)#&')(,3-'")$+#.",+&()/!
!!!
!!.",.%"&4#*7-'")$+#.",+&()/5
!
95643A8!B,8A/,A4!'8246=64238A!
7&! !
!
!
'(')*011! !
55
%3A8!B,8A/,A4!'8246=64238A!
8$6!!
!
!
'(')*++9! !
!
!8#6&!"$7%$,-'")$+#.",+&()/!
5$66/! !
!
'(')*+10! !
!
!!3#669&.9$$-'")$+#.",+&()/5
'(')*+1+! !
!
/"))%&/%.6()"-'")$+#.",+&()/!
!
C,D65--!
!
EF!G!C4615884-!
! :#33&!!
!
!
!
!
!
!
!