DATE: ______ PAWTUCKET SCHOOL DEPARTMENT 286 Main Street

Date: ______Pawtucket School Department 286 Main Street, P.O. Box 388

Pawtucket, Rhode Island 02862-0388

APPLICATION FOR EMPLOYMENT

Non-Teaching

Applicant Information

Last Name / First Name / Middle Initial
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Date Available / Social Security No.
Position(s) Applying For / Lunch Monitor Clerical Custodian Teacher Assistant Other
Are you a citizen of the United States? / YES / NO / If no, are you authorized to work in the U.S.? / YES / NO
Have you ever worked for the Pawtucket School Department? / YES / NO / If so, when?
Have you ever been convicted of a felony? / YES / NO / If yes, explain

EDUCATION (Must provide copy of Diploma or G.E.D.)

High School / Address
From / To / Did you graduate? / YES / NO / Degree
College / Address
From / To / Did you graduate? / YES / NO / Degree
Other / Address
From / To / Did you graduate? / YES / NO / Degree

References

Please list three professional references who are not relatives.
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address
Full Name / Relationship
Company / Phone / ( )
Address

Previous Employment

Company / Phone / ( )
Address / Supervisor
Job Title
Responsibilities
From / To / Reason for Leaving
May we contact this supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact this supervisor for a reference? / YES / NO
Company / Phone / ( )
Address / Supervisor
Job Title / Starting Salary / $ / Ending Salary / $
Responsibilities
From / To / Reason for Leaving
May we contact this supervisor for a reference? / YES / NO

Disclaimer and Signature

I certify that all statements and answers given herein are complete and correct, and further understand that any misrepresentation on this application is reason for immediate dismissal.
Signature / Date

VOLUNTARY INFORMATION

Completion of this portion of the application is STRICTLY VOLUNTARY and will not affect your opportunity for consideration for this position. The information is sought for recordkeeping in compliance with Federal law.
Racial or Ethnic Group: American Indian/Alaskan Asian/Pacific Islander Black/African American
Hispanic/Latino White/Caucasian Other
Gender: Female Male Date of Birth: / / /
Military Service: Veteran Disabled Veteran
Handicapped: Yes No

The Pawtucket School Department does not discriminate on the basis of age, sex, race, religion,

national origin, color or handicap in accordance with applicable laws and regulations.