CALDWELL PARISH SCHOOL BOARD

P. O. BOX 1019

COLUMBIA, LOUISIANA 71418

( ) Teacher Substitute

Application for:( ) Maintenance Position ( ) Clerical Position

( ) Food Service Position ( ) Paraprofessional

( ) Bus Driver( ) Substitute (______)

Area(s) from above list

Name:______

LastFirstMiddle/Maiden

Address:______

Telephone:______Other Telephone:______Date of Birth______

Social Security Number:______

Education

High School:Name & Location ______

Did you graduate with a DiplomaYes No If yes, what year?______

If no, did you earn a GED?Yes No If yes, what year?______

Name the GED Program you attended:______

College:Name & Location:______

(Not a Years Attended:______Degree Earned : (Circle) Associate Bachelors None

vocational If none, indicate number of hours completed:______

school)Major or Course of Study:______

Are you a certified teacher? ___yes ___no

If yes, area(s) of certification:______

State issuing certification:______

*A copy of the original certificate must be submitted in order to receive higher rate of a pay.

Previous Job Experience

Name, address, phone #Supervisor orDatesReason for

Of Business or SchoolPrincipalEmployedLeaving

______From:______

______To: ______

______

______From:______

______To: ______

______

______From:______

______To: ______

______

Personal References

(Other than relatives and those principals or supervisors already listed above)

Please complete fully, including addresses.

Name AddressTelephone Relationship

______

______

______

Would you be willing to substitute in any school in the parish? ___yes ___no

If no, please list choices: 1st______2nd______3rd______

Are you a retiree of a Louisiana School Retirement System? ___yes ___no

If yes, _____Teachers’ Retirement ____School Employees’ Retirement

Have you ever been convicted of a felony? ____yes ____no If yes, state the felony, date, and place of conviction:

______

(A criminal record does not automatically bar employment.)

AUTHORIZATION

*Important: Read carefully and sign

I hereby authorize the Caldwell Parish School Board to conduct a background investigation and I authorize the release of information from previous and current employers, educational institutions, professional and personal references, criminal records, charges and convictions, or other appropriate sources.

I guarantee the correctness of the information in this application. I understand that any omission or false statement made by me in this application or in any documents in connection with it will be sufficient grounds for disqualification from further consideration for employment or for discharge, should I become employed. I also affirm that I have never been convicted of a felony unless listed above.

______

Signature of Applicant Date

The Caldwell Parish School System does not discriminate in hiring or employment or in the provision of services on the basis of race, color, national origin, sex, religion, age, disability, handicap, veteran status, or status within any protected group. No questions on this application are intended to secure information to be used for such discrimination. This application will be given every consideration, but our receipt of it does not imply that you will be offered employment.

OPTIONAL
Personal Information Form
(for statistical use only)
Completion of this information is used for Equal Employment Opportunity statistics and is not related to your application for employment. This information will be used for statistical purposes only. The information you provide will not be included in your application file, nor in your personnel file in the event you are employed. Thank you for providing the requested information.
Ethnic Background: Check all that apply.
/ WHITE (NON-HISPANIC) / / AMERICAN INDIAN/ALASKAN INDIAN
/ BLACK (NON-HISPANIC) / / ASIAN/PACIFIC ISLANDER
/ HISPANIC / / OTHER