NyssaSchool District #26Applicants are considered without regard to

804 Adrian Blvd.race, color, religion, sex, national origin, age,

Nyssa, OR 97913marital status, or the presence of a non-job-

related condition or handicap.

Phone:(541) 372-2275

Fax:(541) 372-2204

APPLICATION FOR EMPLOYMENT

- Classified Staff -

_____Coaching

_____Custodial, Maintenance

_____Food Services

_____Instructional Assistant

_____Secretary, Office Manager

_____Transportation

_____Other ______

Date of Application:______

Date of Availability:______

Name of Applicant:______

LastFirstMiddle(other names used)

Present Address:______

StreetCityStateZIP

Telephone Number:______

Are you within the 18-65 age range?______Social Security Number:______

Are you a member of the Oregon State Retirement System? ______If so, number ______

Voluntary Information

This information is voluntary and is collected for Equal Employment Opportunity reporting purposes. Should you prefer not to provide this information, there will be no effect on your application.

  1. Race or Cultural Group:

_____ American Indian_____ African American_____White

_____ Asian_____ Mexican American_____Other

  1. Sex:_____ Female

_____ Male

  1. Date of Birth: ______
  2. Is your physical/mental health condition such that you can fulfill the essential job functions of the work for which you are applying (either with or without reasonable accommodations)?

_____Yes_____No Explain, if you wish:______

______

______

______

Educational Training:

Name of School / Location / Dates Attended / Degree or Diploma / Date Received
High School
College or University
BusinessCollege
Other Schooling

Previous Employment (A resume may be attached):

Dates
From - To / Former Employer:
(Name/address) / Phone
Number / Job Title / Reason for Leaving

Is there any reason we should not contact the above employers? If yes, please explain: ______

______

I hereby certify that this application contains no misrepresentations or falsifications and that the information given is true and complete to the best of my knowledge and belief. I understand that any omissions from this application may prevent my application from being evaluated. I authorize the NyssaSchool District to obtain information about my criminal records. I authorize all governmental agencies to provide information about my criminal records to the school district. I verify that all information on this employment application is true and complete. I understand that any misrepresentation, falsification, or omission on this application or on other documents submitted to the school district will be sufficient cause for this application not to be considered by the school district or for discharge if I have been employed.

I authorize the NyssaSchool District to check my references, to obtain information from my prior employers and educational institutions, and to take other actions to investigate any information provided in my employment application, and to obtain information relevant to evaluating my qualifications and fitness for a position in the district. I authorize my listed references, past employers and educational institutions, and anyone else who has information about my work history, education qualification, or fitness, to provide such information to the NyssaSchool District. I release the school district and all persons providing information to the school district from any liability for obtaining and providing that information, regardless of the results.

Signature: ______Date: ______

Criminal History Verification for Public School Employment

  1. Have you ever been convicted of a sex-related crime?

Yes _____No _____

  1. Have you ever been convicted of a crime involving violence or the threat of violence?

Yes _____No _____

If yes, was the conviction in Oregon?Yes _____No _____

If no, in what state was the conviction imposed? ______

3.Have you ever been convicted of a crime involving criminal activity in drugs or alcoholic beverages?

Yes _____No _____

If yes, was the conviction in Oregon?Yes _____No _____

If no, in what state was the conviction imposed? ______

4.Have you ever been convicted of any other crime except a minor traffic violation?

Yes _____No _____

  1. Have you been arrested for a crime for which there has not yet been an acquittal or dismissal?

Yes _____No _____

The facts set forth on this application for employment are true and complete to the best of my knowledge. I understand that if I am employed by the NyssaSchool District, false statements on this application shall be considered sufficient cause for dismissal. I hereby grant permission to the district or its agent to check civil or criminal records to verify any statement made on this application.

______

Applicant’s Signature

______

Date

If you are applying for a position in custodial/maintenance, food service, or transportation departments, please turn to the next page.

PLEASE COMPLETE ONLY THE SECTION(S) FOR WHICH YOU ARE APPLYING:

CUSTODIAL/MAINTENANCE

1.For which position(s) are you applying?_____ Custodial_____ Maintenance

2.Please check lines below to indicate any specific maintenance skills you may have:

_____Carpentry_____Electrical_____Grounds

_____Heating_____Plumbing_____Other (please explain below)

______

FOOD SERVICE

  1. Please check entries below to indicate to indicate your specific skills in food preparation:

_____Baking/Pastry_____Menu Planning_____ Other: ______

TRANSPORTATION

1.For which position(s) are you applying?_____ Driver_____ Vehicle Maintenance

2.If driver, please complete the following:

Operator’s License Number:______Expiration Date:______

State in which issued:______

Chauffeur’s License Number: ______Expiration Date:______

State in which issued:______

  1. Have you had a vehicle accident of any type within the last five years? ___ Yes ___ No

If yes, give date(s) and circumstance(s): ______

______

  1. Have you received any citations for any moving violations during the last five years?

___ Yes ___ No

If yes, give number of citations, type, and approximate dates and details of any convictions. ______

______

  1. Has your driver’s license ever been revoked? ___ Yes ___ No

If yes, when? ______Where? ______

Reason: ______

Continued employment as a bus driver is contingent upon the applicant receiving the School Bus Driver’s permit from the Oregon State Department of Education and maintaining an acceptable driving record as verified by the Oregon Motor Vehicles Division.