Application for Employment an Equal Opportunity Employer

FARMINGTON CENTRAL CUSD #265

APPLICATION FOR EMPLOYMENT AN EQUAL OPPORTUNITY EMPLOYER

TODAY’S DATE Click here to enter text. DATE AVAILABLE FOR EMPLOYMENT Click here to enter text.

(Please Print)

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Last Name / First Name / Middle Initial / Social Security # / Date of Birth
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Present Address / City / State / Zip / Phone
Personal Data: Any job offered is conditional upon your ability to establish employment eligibility under the Immigration Reform and Control Act of 1986.
Have you ever interviewed for work at Farmington Central CUSD #265?
When? Click here to enter text. / ☐YES ☐NO
Under What Name? / Click here to enter text. /
Have you ever worked for Farmington Central CUSD #265 before?
When? Click here to enter text. / ☐YES ☐ NO
Under What Name? / Click here to enter text. /
Please indicate name and relationship of any relative employed by District #265: Click here to enter text.
Education: Circle highest year completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Or indicate here if completing digitally: Click here to enter text.
School Name and Location / Graduated
Yes No / Year Grad. / Major Subjects / Degree
High School
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Trade or Tech. School
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College
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Other Training
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Additional Qualifications: Please identify any additional knowledge, skill, or qualification that will be helpful to us in considering your application for employment.
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Job Preference / Please indicate for which position(s) you are applying: Click here to enter text.
Indicate any department preference you have in which to work: Click here to enter text.
Job Performance / Have you been given a job description, or had the requirements of the job for which you are applying explained to you? / ☐YES / ☐No
Do you understand the requirements? / ☐YES ☐NO
Are accommodations needed for you to perform this job? If yes, explain: / ☐YES ☐NO
*The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.
U.S. Military Service / Were you in the Military Services? / ☐YES ☐ NO Branch:Click here to enter text.
Date of Active Duty:
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Click here to enter text. / Highest Rank:
Click here to enter text. / Special Training:
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Convictions / (Do not list ordinance violations or traffic violations) (Except when applying for a job requiring driving)
Have you ever been convicted of a felony or misdemeanor which has not been ordered expunged, sealed or impounded? (Disclosure of criminal conviction will not result in disqualification from consideration) / ☐YES ☐NO
If yes, for each offense: Where? Click here to enter text. / When? Click here to enter text.
Why? Click here to enter text. / Final Action? Click here to enter text.
Other than a traffic offense, have you ever engaged in illegal conduct, even if not charged, indicted or convicted? / ☐YES ☐NO
If so, what, when and where? Click here to enter text.
Have you ever been determined a perpetrator of child abuse or neglect in a Department of Children and Family Services (“DCFS”) report? / ☐YES ☐NO
If so, explain?
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Employment History / Please list below your present and previous four employers (most recent first). Include Teaching Experience.

Employer Name: Click here to enter text.

Employer Name: Click here to enter text.

Employer Name: Click here to enter text.

Employer Name: Click here to enter text.

Address Street
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Job Title Click here to enter text. / Name of Immediate Supervisor: Click here to enter text. / Supervisor’s Title: Click here to enter text.
Employment Start Date:
Click here to enter text. / Employment End Date:
Click here to enter text. / Salary When Employment Ended:
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Duties: Click here to enter text.
Reason for Leaving: Click here to enter text.
Have you ever been asked to resign from any employment? / ☐YES ☐NO
If yes, list the name, address and phone number of the employer and explain the reason(s) you were asked to resign.
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References: Give below the names of three persons not related to you whom you have known in a professional capacity at least one year and have personal knowledge of your fitness as an employee.
Name / Phone # / Relationship / Occupation / Years Acquainted
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Candidate’s Statement:
Each candidate is required to provide in handwritten form on a separate sheet of paper, any additional information that is pertinent to this application and will assist the district in evaluating the candidate’s qualifications (i.e., personal qualities, future goals, awards, travel, involvement in community activities, etc.) If you need additional space, attach more pages. IT IS IMPERATIVE THAT YOUR ANSWERS AND EXPLANATIONS ARE COMPLETE.
Certification:
I hereby certify that the information given by me in this application is true, correct and complete; and, I hereby authorize personnel in the district to examine my records and contact any of my schools, former employers or other references for the purposes of collecting information regarding my employment, education, certification, experience and fitness as an employee. I authorize such schools, former employers or other references, and any current or former officers, agents or employees thereof to disclose information regarding my employment, education, experience and fitness as an employee, and I agree to hold any and all of such schools, former employers, references and persons harmless and free of any liability for releasing any truthful information about me.
I understand that failure to provide any information requested in this application which is material to my qualifications for employment or the provision of statements which I do not believe to be true may be a Class A Misdemeanor. For purposes of this application, I shall be deemed to have made a false statement if I make a statement which I do not believe to be true or if I knowingly omit or fail to include any information required to be furnished on this application.
I understand that if I am employed, any false or misleading statement made or implied on this application, any omission of required information, or any inconsistency between the information I have provided herein and information obtained from any criminal history records check, Statewide Sex Offender Database check, Statewide Child Murderer and Violent Offender Against Youth Database check, or other background investigation may result in immediate dismissal. I further understand that my employment or continued employment is contingent upon the District’s receipt of a criminal history records report which is acceptable to the Board of Education.
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SIGNATUREDATE
APPLICATION REMAINS ACTIVE FOR ONE YEAR - REAPPLICATION IS NECESSARY AFTER THAT TIME
Do not write in this box. For District Use Only:
Date of Interview ______Time ______Interviewed by ______
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