CANBY PUBLIC SCHOOLS
INDEPENDENT SCHOOL DISTRICT NO. 891
APPLICATION FOR CLASSIFIED PERSONNEL POSITIONS
I. EQUAL EMPLOYMENT OPPORTUNITY
It is the policy of Independent School District No. 891 to provide equal employment opportunity for all, without discrimination on the basis of race, color, creed, religion, national origin, gender, marital status, status with regard to public assistance, disability, sexual orientation, or age.
II. DATA PRIVACY NOTICE
The information requested on this application may be used by the School District in determining suitability for employment for the position which you are currently seeking or may seek in the future. You are not legally required to provide any of the information on this form at this time. However, failure to provide complete accurate information may result in the School District being unable or unwilling to offer employment to you. With respect to any special accommodations necessary for completing your application or the interview process, the School District may be unable to provide the necessary accommodations if you do not provide the requested information. The information on this application which is classified as private data under the Minnesota Government Data Practices Act will not be released outside the School District without your consent except as necessary for tax purposes or as otherwise required by state or federal law.
III. POSITION DESIRED
Title of position for which you are applying:___________________________
Date available to begin employment:_________________________________
IV. PERSONAL DATA
Name_________________________________________________________
Last First Middle
Social Security No.______________________________________________
Address_______________________________________________________
Street City State Zip
Phone Number__________________________________________________
E-Mail Address_________________________________________________
Are you either a U.S. citizen or legally eligible to hold employment in the United States? Yes_______ No_________
Have you previously worked for Independent School District No. 891?
Yes______ No_______ If yes, position held:_______________________________
If yes, under what name may your previous employment records be found?_________
____________________________________________________________________
Do you have any special needs which may necessitate accommodations in the application/interview process? Yes________ No_________ If yes, please describe the type of accommodation requested:_________________________________________
____________________________________________________________________
____________________________________________________________________
List all other names under which you have been employed or under which your educational records may be found.
____________________________________________________________________
____________________________________________________________________
V. WORK/VOLUNTEER EXPERIENCE
List all work and volunteer experience, most recent to be listed first.
Employer Name:______________________________________________________
Employer Address:____________________________________________________
Job Title:____________________________________________________________
Job Duties:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
Date of employment/experience:__________________________________________
Reason for leaving:____________________________________________________
Employer Name:______________________________________________________
Employer Address:____________________________________________________
Job Title:____________________________________________________________
Job Duties:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
Date of employment/experience:__________________________________________
Reason for leaving:____________________________________________________
Employer Name:______________________________________________________
Employer Address:____________________________________________________
Job Title:____________________________________________________________
Job Duties:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
Date of employment/experience:__________________________________________
Reason for leaving:____________________________________________________
Employer Name:______________________________________________________
Employer Address:____________________________________________________
Job Title:____________________________________________________________
Job Duties:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
Date of employment/experience:__________________________________________
Reason for leaving:____________________________________________________
Employer Name:______________________________________________________
Employer Address:____________________________________________________
Job Title:____________________________________________________________
Job Duties:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
Date of employment/experience:__________________________________________
Reason for leaving:____________________________________________________
Attach additional sheets if necessary.
VI. LICENSURE
List current licenses, registrations, or certificates relevant to the position for which you are applying.
License/No. Issued By Date Expiration
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
All applicable licenses or certifications must be received in Superintendent’s office prior to employment.
VII. EDUCATION
Include high school and any additional education/courses taken. List most recent first.
Name of School:______________________________________________________
Address of School:____________________________________________________
Degree/Diploma Received:_______________________________________________
Major/Minor:_________________________________________________________
Dates of Attendance:___________________________________________________
Name of School:______________________________________________________
Address of School:____________________________________________________
Degree/Diploma Received:_______________________________________________
Major/Minor:_________________________________________________________
Dates of Attendance:___________________________________________________
Name of School:______________________________________________________
Address of School:____________________________________________________
Degree/Diploma Received:_______________________________________________
Major/Minor:_________________________________________________________
Dates of Attendance:___________________________________________________
VIII. REFERENCES: These should be people in a position to discuss your qualifications for the position you seek. Include especially managers, directors, or heads of departments under whom you have worked. Indicate any who are related you. The School District reserves the right to contact all prior employers, educational institutions or institutions where you have volunteered in addition to references listed below.
Name of Reference:____________________________________________________
Address:_____________________________________________________________
Phone Number:__________________________ Title:_________________________
Name of Reference:____________________________________________________
Address:_____________________________________________________________
Phone Number:__________________________ Title:_________________________
Name of Reference:____________________________________________________
Address:_____________________________________________________________
Phone Number:__________________________ Title:_________________________
IX. CRIMINAL BACKGROUND INFORMATION
Have you ever been charged with a misdemeanor or a felony?___________________
If yes, please explain the nature of the charge and the circumstances:______________
____________________________________________________________________
Were you convicted and/or did you plead guilty?______________________________
Give the date, city, state and county where convicted:__________________________
The School District will conduct a criminal background check on individuals upon making a contingent job offer. No offer of employment shall become final until receipt of the results of the criminal background check from the BCA, the content of which is acceptable to the School District, and approval by the School Board.
X. VETERAN STATUS
Are you an honorably discharged veteran of the armed forces of the United Sates or are you otherwise eligible to claim Veteran’s Preference Points? Yes________ No________
Do you wish to claim Veteran’s Preference Points? Yes_________ No_________
If you are a disabled veteran and wish to claim additional points, please check here.______
XI. PRIOR EMPLOYMENT
Have you ever been discharged or forced to resign from prior employment?___________
If so, describe the circumstances:_____________________________________________
_______________________________________________________________________
_______________________________________________________________________
XII. PERSONAL STATEMENT
Please indicate why you are interested in the position and what you hope to accomplish if selected._______________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
XIII. CERTIFICATION, ACKNOWLEDGMENT AND RELEASE
I certify that the answers I have given on this application are true and correct to the best of my knowledge. I understand that any false or misleading information provided, or any omission or concealment of facts, will disqualify me from consideration for employment, and constitutes grounds for my immediate dismissal should I be employed by the District.
In connection with this application I hereby authorize any and all former employers and references named in this application, or any agent of such a former employer, to release to Independent School District No. 891 and its agents any and all information regarding my job performance and fitness/qualifications to perform the position I am presently seeking and any other employment or related information, both public and private, in their possession. I understand that Independent School District No. 891 will use this information to determine my fitness/qualifications for the position I am seeking. This authorization expires one year from the date of my signature, below. I hereby release Independent School District No. 891 and all former employers and references listed herein and any and all agents acting on behalf of said District, former employers or references, for any and all liability of whatever nature by reason of requesting or providing such information.
Date______________________ Signature___________________________________
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