Santa Maria-Bonita School District

708 S. Miller Street

Santa Maria, CA 93454-6230

(805) 928-1783 extension 8127

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JOB POSITION APPLIED FOR: / TODAY’S DATE
MO / DY / YR
NAME:
First / M.I. /
Last
ADDRESS:

Street Address

City State Zip Code
TELEPHONE: / Home
( ) - / Message
( ) - / May we contact you at work?
Yes No
E-Mail Address

SOCIAL SECURITY NUMBER: - - CA DRIVERS LICENSE #

Disclosure of your social security number is voluntary. The social security number Disclosure of your driver’s license number is voluntary

will be used for identification purposes to ensure that proper records are maintained

Human Resources Use Only

Documents that need to be provided prior to testing:
¡ Verif. Of HS Diploma or equivalent ¡ Degree Verif.
¡ DMV Printout ¡ Typing Certificate
¡ CPR Certificate ¡ First Aid Certificate
Date Reviewed: ______Reviewed By: ______
INVITE TO TEST: ¨ YES ¨ NO
Interview Date: ______Outcome:______/ Date Test Title Score
Notes/Comments: / References: ______
Fingerprints: DOJ received: ______
FBI received: ______
Physical Exam: ______
TB: ______EDD: ______


WORK EXPERIENCE: Begin with the most recent experience and account for all time (including periods of unemployment) in the last ten years. List any jobs you held more than ten years ago that relate to the duties of the job for which you are applying. List any volunteer experience which relates to the job for which you are applying. Attach a separate sheet if you need more space.

DATES
From: To:
MO. YR. MO. YR. / Your job title:
Your duties:
Reason for leaving: / Employer’s / Organization’s Name
Address:
Supervisor’s Name:
Telephone:
May we contact your present employer for a reference YES NO
TOTAL TIME: YRS MOS
Hours per week:
SALARY $ HR.
MO. WK.
VOLUNTEER MO.
DATES
From: To:
MO. YR. MO. YR. / Your job title:
Your duties:
Reason for leaving: / Employer’s / Organization’s Name
Address:
Supervisor’s Name:
Telephone:
TOTAL TIME: YRS MOS
Hours per week:
SALARY $ HR.
MO. WK.
VOLUNTEER MO.
DATES
From: To:
MO. YR. MO. YR. / Your job title:
Your duties:
Reason for leaving: / Employer’s / Organization’s Name
Address:
Supervisor’s Name:
Telephone:
TOTAL TIME: YRS MOS
Hours per week:
SALARY $ HR.
MO. WK.
VOLUNTEER MO.
DATES
From: To:
MO. YR. MO. YR. / Your job title:
Your duties:
Reason for leaving: / Employer’s / Organization’s Name
Address:
Supervisor’s Name:
Telephone:
TOTAL TIME: YRS MOS
Hours per week:
SALARY $ HR.
MO. WK.
VOLUNTEER MO.
DATES
From: To:
MO. YR. MO. YR. / Your job title:
Your duties:
Reason for leaving: / Employer’s / Organization’s Name
Address:
Supervisor’s Name:
Telephone:
TOTAL TIME: YRS MOS
Hours per week:
SALARY $ HR.
MO. WK.
VOLUNTEER MO.

List any other skills, abilities, training and/or experience that would qualify you for this position. Include volunteer experience. Attach copies of any certificates (verification of training) that would be applicable. ______

EDUCATION

(NOTE: Documentation of level of education is required. Attach a copy of diploma or degree)

HIGH SCHOOL EDUCATION
School Granting Diploma:
Year Graduated: Type of Diploma: High School Diploma
High School Proficiency Certificate
GED
Adult Education Diploma
COLLEGE EDUCATION
Check your highest education level: Associates Degree Bachelors Degree Masters Degree
SCHOOL GRANTING DIPLOMA or DEGREE:
COLLEGE ATTENDED:
COLLEGE UNITS COMPLETED: MAJOR:
OF COLLEGE UNITS, ARE ANY IN EARLY CHILDHOOD STUDIES? YES NO IF YES, # OF UNITS:
TRADE OR BUSINESS SCHOOL
Name of Trade or Business School:
Type of Degree or Certificate Obtained:
Do you speak, read and/or write a language other than English?
LANGUAGE: SPEAK READ WRITE
LANGUAGE: SPEAK READ WRITE / YES NO

CERTIFICATES AND LICENSES

To answer the following questions, refer to the job description under the area of “LICENSES AND OTHER REQUIREMENTS” and/or “ABILITY TO”. If a license or certificate is required, your application will not be considered complete unless you attach a copy of the certificate or DMV report.

Does the position that you are applying for require a FIRST AID CERTIFICATE?
If “Yes”, attach a copy of your certificate (no more than 3 years old) EXPIRATION DATE: / YES NO
Does the position that you are applying for require a CPR CERTIFICATE?
If “Yes”, attach a copy of your certificate (no more than one year old) EXPIRATION DATE: / YES NO
Does the position that you are applying for require a typing certificate?
If the job description requires a certain typing speed, a typing certificate must be attached in order for this application to be considered complete. The certificate must reflect a five-minute test with no more than five errors that has been issued within the past six months. Errors are deducted from the gross speed and the net amount is considered as the typing speed. For example: 62 wpm with 4 errors = 58 wpm.
If “Yes”, attach a copy of your certificate Date of Certification:
Net Corrected Speed (wpm): / YES NO
Does the position that you are applying for require a California Drivers License?
If “Yes”, attach a copy of a DMV printout issued within the last 30 days / YES NO

PERSONAL DATA AND HISTORY

1. / Have you ever been employed by the Santa Maria-Bonita School District?
If yes, under what name?
If yes, dates of employment: Position: / YES NO
2. / Have you ever been a member of the Public Employee’s Retirement System?
If the answer is yes, through what agency were you employed?
Were the funds withdrawn? YES NO / YES NO
3. / Are you currently working for another school district or government agency?
If you are employed by another agency that is a member of PERS, concurrent employment with the Santa Maria-Bonita School District may result in mandatory enrollment in the Public Employees Retirement System. / YES NO
4. / Are you a United States Citizen?
IF NO do you have the legal right to work in the United States? YES NO
(If offered employment, you will be required to submit proof of your legal right to work in the United States.) / YES NO
5. / Have you been dismissed, resigned from, or otherwise left employment because of allegations of misconduct?
If the answer is yes, please state the details: / YES NO
6. / Have you ever been convicted of any felony or misdemeanor offense, including entering a plea of nolo contendere, in California or any other place? If the answer is yes, please state when, where, and the disposition of the case. Attach a separate sheet if you wish to explain the incident.
A conviction will not automatically bar you from consideration for employment. However, if you fail to disclose the fact of a conviction, that failure will result in disqualification from the employment process. Education Code prohibits hiring individuals convicted of narcotics or sex offenses, or serious and violent crimes. Fingerprint criminal history clearance is required by law of all school employees prior to date of employment.
Offense: Date:
Court: Disposition: / YES NO
If yes:
Date(s)
Offense Code #
7. / Can you perform the essential functions of the position with or without reasonable accommodation?
(Note: Essential functions are listed on the job description and indicated with an “E”. / YES NO
8. / Have you served in the Armed Forces of the United States?
Branch: Service Occupation:
Did you receive an honorable discharge? Yes No If no, what type? / YES NO

I hereby authorize the Santa Maria-Bonita School District to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize my former employers to disclose to the Santa Maria-Bonita School District any and all of my employment records, including disciplinary records. In addition, I hereby release the Santa Maria-Bonita School District, my former employers, and all other persons from any and all claims, demands and liabilities arising out of, or in any way related to, such an investigation or disclosure.

By submitting this application I hereby certify that the statements made on this application are true and correct to the best of my knowledge. I further certify that I have not knowingly withheld any information that might adversely affect my chances for employment with the District. I understand that any omission or misstatement of material fact on this application or any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I understand that a condition of employment is that I sign a loyalty oath, submit verification of my legal right to work in the United States and, if required, pass a medical examination. I understand that I also must be tested for and be free of active tuberculosis. I understand that employment into a position that requires a Class-A driver’s license will require me to submit to random drug testing. I further understand that I must submit my fingerprints for processing by the Department of Justice and that I may not be employed by the District until that process is completed.

Signature of Applicant Date

H:\u\ps\forms\classapp rev. 07/01/10

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