RONDOUT VALLEY CENTRAL SCHOOL DISTRICT Classified Employment Application Personnel * P.O. Box 9 * Accord, New York 12404 * Phone: (845)687-2400 Date(s) of Interview Job(s) Applied for: [ ] Full Time [ ] Part Time Interviewer: [ ] Substitute [ ] Temporary Recommended Assignment: As For Building Effective Date Rate Comments [ ] Teacher Aide [ ] Clerical [ ] Registered Nurse [ ] Custodial Worker [ ] Cafeteria [ ] Other Date: PERSONAL INFORMATION Name Last First Middle Initial Address Years at above address Social Security Number - - Telephone No. e-mail address New York State Employee s Retirement System No. (if a member) Are you capable of substantially performing the duties of the job for which you are making this application, with or without a reasonable accommodation? Yes No. If a reasonable accommodation is requested please state the nature of the reasonable accommodation. List any person working for us who know you Please write yes if you are a U.S. military veteran volunteer firefighter. Did you ever receive a discharge from the Armed Forces of the United States which was other than honorable? Yes No In your most recent position, how many days were you absent during your last year of employment due to Personal Illness Family Illness Bereavement Personal Business? Please include two written letters of reference
PERSONAL INFORMATION (Continued) Have you ever been convicted of a crime*(felony or misdemeanor)? Yes No. If Yes please answer the following questions: 1. What crime or crimes were you convicted of? 2. What year was the crime committed? What year were you convicted? 3. What court convicted you and where was it located: Court Location 4. Did you serve time? Yes No. If Yes when will your parole end? 5. List all of your employment since the time of your release from prison. *Please note: conviction of a crime will not necessarily exclude an applicant from employment; each case will be judged on a case by case basis. 2
EMPLOYMENT EXPERIENCE List most recent experience first. List all prior employers. Use additional sheets if needed. Name Phone Number and Address of Employer From: Mo. Yr. To: Mo. Yr. Supervisor s Name Reason for Leaving Annual Salary Describe in detail the work you did. Name Phone Number and Address of Employer From: Mo. Yr. To: Mo. Yr. Supervisor s Name Reason for Leaving Annual Salary Describe in detail the work you did. Name Phone Number and Address of Employer From: Mo. Yr. To: Mo. Yr. Supervisor s Name Reason for Leaving Annual Salary Describe in detail the work you did. Name Phone Number and Address of Employer From: Mo. Yr. To: Mo. Yr. Supervisor s Name Reason for Leaving Annual Salary Describe in detail the work you did. 3
EMPLOYMENT EXPERIENCE (Continued) Indicate any Employers listed, you do not wish us to contact. Have you ever been released from or asked to resign an employment position? Yes No. If Yes explain. 4
EDUCATIONAL PREPARATION Name & Location of School Major Minor Diploma or Degree Granted High School College Business or Trade Other ACTIVITIES Activities in High School, College, Community which are relevant to the position for which you are applying. Awards, Honors, Recognition REFERENCES Give the names of three references who have closely observed your work as an employee or student. Recommendations by present and former supervisors and principals are preferred. Please print. Name Position Address Telephone ( ) Name Position Address Telephone ( ) Name Position Address Telephone ( ) 5
PLEASE FILL OUT ADDITIONAL INFORMATION ONLY FOR THE PARTICULAR POSITION FOR WHICH YOU ARE APPLYING. TEACHER AIDE Indicate experiences that qualify you for working with students in a supervisory or instructional setting CLERICAL Your average typing speed W.P.M. Do you take Shorthand?. If yes, speed W.P.M. do you have any computer experience?. If yes, Please explain Do you have a preference or background for working in a specific program?. If yes, please explain. Have you taken any civil Service examinations for clerical positions?. If yes, when Where? Title(s) Score(s) Are you interested in substitute work in this area? Yes No. REGISTERED NURSE Do you have a currently valid New York State RPN license? License # Effective date Expiration date Do you have nursing experience in a school setting or with children? If yes, please explain. Are you interested in substitute work in this area? Yes No. CAFETERIA Indicate experiences that qualify you for working in a school cafeteria setting. CUSTODIAN/ CUSTODIAL WORKER Are you interested in substitute work in this area? Yes No. Have you had experience or training in institutional cleaning If yes, explain Have you ever supervised others in an institutional cleaning operation? If yes, please explain Have you ever taken any civil Service Examinations for custodial positions? If yes, When? Where? Title(s) Score(s) Are you interested in substitute work in this area? Yes No 6
MAINTENANCE Indicate experience or training that qualifies you Type of Driver s License* *Answer only if position applied for requires driving. Have you been convicted of a moving violation(s), (e.g. reckless driving, speeding, etc.) during the last 5 years? If yes, give: Date: Charge: Disposition: Court and Location: Have you ever been involved in an automobile accident which caused injury or death to anyone? Yes No. If yes, please explain, give dates and outcome Have you ever taken any Civil Service examinations for Maintenance positions? If yes, When? Where? Title(s) Score(s) Are you interested in substitute work in this area? Yes No COACH Position applied for Indicate previous coaching experience First Aide Certification: Yes [ ] No [ ] CPR Certification: Yes [ ] No [ ] Expiration Date Mo. Day Yr. Expiration Date Mo. Day Yr. 7
AUTHORIZATION I hereby authorize you to make any investigation of my personal history, including criminal record check, financial credit and employment record. I waive my right of access to any information provided by record. I waive my right of access to any information provided by references or other sources in the process of investigating my personal background and work record. Signature Date AFFIRMATION Inaccurate answers or falsification of any statements and/or accompanying documents may result in disqualification from employment, withdrawal of an offer of employment, or dismissal from employment. I declare and affirm that the statements made in this application and any accompanying documents are true, complete, and correct. Signature of Applicant Date The Rondout Valley Central School District does not discriminate on the basis of age, color, religion, creed, marital status, veteran status, national origin, race, or gender in its educational programs, activities, and/or hiring. In addition, the District does not discriminate on the basis of disability and hereby acknowledges its obligation not to discriminate and encourages persons with disabilities to contact it in regard to reasonable accommodations. Inquiries concerning this policy of equal opportunity should be referred to the District s Office of the Assistant Superintendent. Rondout Valley Central School District. P.O. Box 9, Accord, New York 12404. 8