Concrete School District #11

45389 Airport Way, Rm #103

Concrete, WA 98237

(360) 853-8141 • Fax (360 853-7521

CLASSIFIED EMPLOYMENT APPLICATION

GENERAL INFORMATION:

  1. All applicants must include the following:
  2. Typed letter of recommendation
  3. Current resume
  4. Three letters of reference from a previous employer
  5. Completed application
  6. All application materials become the property of the Concrete School District #11 and cannot be returned.
  7. In compliance with Federal and State equal opportunity employment laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, or the presence of a handicap or disability.
  8. Federal and State criminal history background checks will be required of candidates who will or may have unsupervised access to children or developmentally disabled persons. Any offer of employment is conditional and subject to acceptable outcome of a criminal history background check, the return of a sexual misconduct form and school board approval.
  9. For complete information regarding a position, please consult the job posting found in the school district office or the Concrete School District web site.

Print or type. Only completed applications will be considered.

Legal Name:

Last: Middle: First: Date of Application:

Other name(s) under which records may be listed: Social Security #

Current address: Street PO Box:

City: State: Zip:

Home phone: Cell phone: Business phone:

E-mail:

Have you ever been employed in other school districts? Yes NoWhere:

Please check the position for which you are applying:

Bus driver Custodial Other:

Clerical Grounds/Maintenance

Food service Mechanic

Educational assistant Health professional

Have you ever been a member of the Washington Retirement System? Please check any that apply:

TRS PERS SERS LEOFF Other:

Availability for employment (please check):

Full-time Part-timePlease specify desired hours

E-mail address:

What is your current position?

For school district use only

Date received

List the names of educational and technical institutions that you have attended (list high school first) / Location of schools or institutions
City, State, Country / Dates attended
From To / Course of study / Certificate, degree, number of credits received

List other licenses and special training you possess that may relate to this position.

Indicate skills/knowledge specific to the job for which you are applying.

Answer only for positions where holding a valid Washington State driver’s license is an essential job function.

Do you have a valid Washington State driver’s license? Yes NoLicense number:

The specific paraprofessional requirements went into effect on January 8, 2002 and apply to all paraprofessionals and instructional duties working in programs supported by Title I Part A funds.

Are you applying for a paraprofessional instructional position? Yes No

If you responded “Yes”, please check which of the following you possess:

Completed minimum of 72 quarter credits of study in an institution of higher learning (official transcript required).

Obtained an associates (or higher) degree (official transcript required).

Met a rigorous standard by passing a formal state academic assessment for paraprofessionals (official document on file).

Please give an accurate and complete full-time/part-time employment record. Start with present or most recent employer. If more space is needed, attach an additional sheet of paper.

State job title and describe your work assignment / Reason for leaving?
Company name: / Type of business:
Address: / Phone:
Name of supervisor: / Rate of pay mo wk yr
Employment dates (month & year)
From To / Start $
Last $
State job title and describe your work assignment / Reason for leaving?
Company name: / Type of business:
Address: / Phone:
Name of supervisor: / Rate of pay mo wk yr
Employment dates (month & year)
From To / Start $
Last $
State job title and describe your work assignment / Reason for leaving?
Company name: / Type of business:
Address: / Phone:
Name of supervisor: / Rate of pay mo wk yr
Employment dates (month & year)
From To / Start $
Last $

APPLICANT DISCLOSURE STATEMENT

Pursuant to the requirements of RCW 43.43.834, the Concrete School District must as you to complete the following Applicant Disclosure Statement. This information will be kept confidential. Please answer fully and accurately.

Note: the Concrete School District will confirm your answers to these questions by:

  • Running a Washington State Patrol check/or criminal convictions.
  • Searching the Washington Courts databases for civil adjudications as listed below; and,
  • [Healthcare only] For licensed personnel, checking the Department of Health credentials database for disciplinary actions.

You will be notified of the State Patrol’s response within ten days after we receive the report. We will make a copy of the report available to you upon your request.

  1. Have you ever been convicted of a crime? Yes No

If “Yes” please identify the offense(s), provide the date)s) of the conviction(s), the name of the court (e.g. King County Superior Court), and the sentence(s) imposed.

  1. Have you ever had findings made against you for domestic violence, abuse, sexual abuse, neglect, exploitation or financial exploitation of a child or a vulnerable adult in any civil adjudicative proceeding? Civil adjudicative proceeding includes judicial or administrative proceedings as well as findings by DSHS or the Department of Health that you have not administratively challenged or appealed. Yes No

If “Yes” please identify the specific finding(s), which agency or court made the finding(s), the date(s) of the finding(s) and the penalty(ies) imposed.

  1. Do you hold a current Teaching Certificate? Yes No

If “yes”, is it under review in any jurisdiction? Yes No

If “yes”, explain:

I declare, under penalty of perjury under the laws of the State of Washington, that the foregoing is true and correct. I understand that if I am hired, I can be discharged for any misrepresentation or omission in the above statement. I also understand that if hired, my employment is conditional on satisfactory results of the background checks listed above. I have signed this Disclosure Statement on the date shown below at Washington.

Date:

Type name:

(Note, you must print this form before signing and returning it to the district office)

Signature:

Supplemental Form

  • Does your visa or immigration status prevent you from lawfully becoming employed in the U.S.A.? (You will be required to furnish proof of U.S. citizenship or alien identification documents entitling you to work if you are hired.)

Yes No

  • Within the last seven years, have you been convicted of any crime or served time in jail following conviction of a crime? If “Yes”, give the dates and explanation. (Conviction does not automatically exclude you from consideration for employment.)

Yes No

  • Are you able to perform the duties and tasks of the position for which you are applying with or without accommodation or assistance?

With accommodation

Without accommodations

If accommodations or assistance will be required, please explain how you would perform the duties/tasks, and with what accommodations.

  • Do you have any relatives currently employed by (or serving as a member of the Board of Directors of Concrete School District #11)? Answering “Yes” to this question will not exclude an applicant from consideration, but is used to prevent placement which may create a conflict of interest.

Yes No

INVESTIGATION CONSENT AND RELEASE OF LIABILITY FORM

I certify that all statements made by me on this application are true and complete. I understand that misrepresentation or falsification of statements made in the application constitutes grounds for immediate dismissal.

I authorize Concrete School District #11 to make an investigation of my personal, educational, vocational, or employment history. I further authorize any former employer, firm, corporation, educational or vocational institution, or government agency to provide Concrete School District #11 with any information they have regarding me. I hereby release and discharge Concrete School District #11 and all those who provide information from any and all liability as a result of furnishing and receiving this information.

Signature of Applicant:

Date signed:

Please submit the following:

Completed Application

Resume

Letter of Application

Letters of Reference

Completed sexual misconduct form(s), if applicable

Send to:

Personnel

Concrete School District

45389 Airport Way, Rm #103

Concrete, WA 98237