Application for Professional Employment

Hinsdale Central School

3701 Main Street

Hinsdale, NY 14743

Phone: 716-557-2227

www.Hinsdalebobcats.org

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

Today’s Date: ______

Position For Which You Are Applying:

 Teacher (Specify Area): ______

 Substitute: __Certified ___Uncertified ___4-year degree ___2-year degree

 Administrative (Be Specific): ______

Personal Information:

Last Name First Name Middle Name

Current Address: Street City State Zip Code

Permanent Address: Street City State Zip Code

______

Home Telephone Number Cell Phone Number

E-mail Address

Best time to contact you is: ______: am/pm

STATE AND FEDERAL LAW PROHIBITS DISCRIMINATION IN EMPLOYMENT BECAUSE OF FACTS SUCH AS AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, SEX, DISABLILTY, MARITAL STATUS, OR ARREST RECORD. ACCORDINGLY, NOTHING IN THIS APPLICATION FORM SHOULD BE VIEWED AS EXPRESSING, DIRECTLY OR INDIRECTLY, ANY LIMITATION, SPECIFICATION AS TO ANY FACTORS PTROTECTED BY LAW IN CONNECTION WITH EMPLOYMENT.

Have you ever been convicted of a crime? YES NO

Have you ever been disciplined or fired from a job? YES NO

Have you ever been denied tenure? YES NO

Have you ever resigned from employment rather than face dismissal? YES NO

Have you ever had a teaching credential revoked, suspended or annulled? YES NO

Is there any reason known to you, other than medical, mental or physical

disability, why you might be unable to perform consistently and promptly

any of the job duties of the position for which you are applying? YES NO

Are you unable to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? YES NO

None of the above circumstances represents an automatic bar to employment. Each case is considered and evaluated on individual merits in relation to the duties and responsibilities of the position(s) for which you are applying.

If “YES” was answered to any of the above questions, please provide additional, specific information:

Education:

Please list your education credentials beginning with the most recent:

Institution / Degree / Date Earned

Certification Information:

I hold the following NEW YORK STATE teaching and/or administrative certificates:

Area / Certificate of Qualification / Provisional / Provisional Expiration Date / Permanent

List any valid certificates currently held in other states:

Area: ______Issuing State: ______Exp. Date: ______

Have you successfully completer the Core Battery NYSTCE Exams for New York State? Yes No

Have you taken the two-hour seminar on identification of child abuse & neglect? Yes No

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer:
Address:
Telephone:
Dates of Employment: From: To:
Position Title: Salary:
Reason for Leaving:
Employer:
Address:
Telephone:
Dates of Employment: From: To:
Position Title: Salary:
Reason for Leaving:
Employer:
Address:
Telephone:
Dates of Employment: From: To:
Position Title: Salary:
Reason for Leaving:

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:

State any additional information you feel may be helpful to us in considering your application.

References (list three non-relatives willing to recommend you):

Name:
Address:
Telephone: Home: Business:
Name:
Address:
Telephone: Home: Business:
Name:
Address:
Telephone: Home: Business:

Applicant’s Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

______

Signature of Applicant Date