Riverside COMMUNITY SCHOOL DISTRICT

Riverside Community School District

Application for Employment

RIVERSIDECOMMUNITYSCHOOL DISTRICT

Serving the communities of Carson, Macedonia and Oakland

Dr. Tim Mitchell, SuperintendentPhone (712) 484-2291 P.O. Box 218, Carson, Iowa 51525 Fax (712) 484-3957

The mission of the RiversideCommunitySchool District is to prepare students to meet the challenges

Of the future as responsible citizens in a global society.

Dear Prospective Employee:

Thank you for your interest in Riverside Community Schools. All pages in the application packet must be completed to insure accurate consideration. Please feel free to attach other documentation you feel best qualifies you for employment with Riverside Schools. Please contact the Business Office at 712-484-2291 with any questions.

PERSONAL:

Name: ______Date: ______

Address: ______

City: ______State: ______Zip: ______

Home Phone Number: ______Social Security Number: ______

Have you been employed by Riverside Community School District before? ______

If so, position? ______Dates ______

Position now applying for: ______

Earnings expected $ ______per year or $ ______per hour.

When are you available to begin work? ______

Are you interested in overtime work? ______

Are you legally eligible for employment in the United States? ______

Have you ever been convicted of a anything other than a non-moving traffic violation? ______

If yes, please explain______

(Note: Conviction will not necessarily disqualify applicant from employment.)

Do you have relatives working for Riverside? ______

If yes, please list names ______

Please review the job description for the job in which you are interested.

Is there any reason you could notperform the duties listed as essential functions for that job? ______

If yes, please explain ______

If you answered yes to the previous question, what accommodations, if any, would you suggest?

______

EDUCATION:

Elementary School: ______(If more than one, name last attended)

High School: ______Year Graduated: ______

College/University: ______

Course of Study: ______Degree: ______Year: ______

Did you receive any special honors? ______

Please describe: ______

Describe any licenses, apprenticeships, or specialized training you possess:______

______

MILITARY: (If related to the requirements of the job or if you are claiming veterans preference)

Active Duty Branch: ______Period of Duty: ______

Location of Duty: ______Rank at Discharge: ______

Reserve Duty Branch: ______Period of Obligation: ______

List times of current active duty training: ______

PRIOR EMPLOYMENT:(List employers for the past 10 years.)

Employer: ______

Address: ______Phone: ______

Your job: ______

Period of Employment: ______

Reason for leaving: ______

Employer: ______

Address: ______Phone: ______

Your job: ______

Period of Employment: ______

Reason for leaving: ______

Employer: ______

Address: ______Phone: ______

Your job: ______

Period of Employment: ______

Reason for leaving: ______

Employer: ______

Address: ______Phone: ______

Your job: ______

Period of Employment: ______

Reason for leaving: ______

Please list professional or civic organizations to which you belong: ______

______

APPLICANT’S STATEMENT:

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that any false information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorize a thorough investigation into my past employment and activities, agree to cooperate in such investigation, and release from all liability or responsibility all persons or corporations requesting or supplying such information. I recognize that, when considering my application, the school corporation may contact the employers I listed previously. I hereby authorize a representative from each such employer to discuss all aspects of my employment with the school corporation and to disclose any and all documents regarding that employment.

I understand that according to federal law all individuals who are hired must, as a condition of employment, produce certain documentation to verify identity and U.S. citizen status or, if aliens, their legal authorization to work in the U.S. I understand that any offer of employment will, therefore, be contingent on my ability to produce the required documentation with the time period required by law.

Signature of Applicant: ______

Release Authorization

In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance and experience, along with reason for termination and employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: worker’s compensation injuries, driving record, court record, education, credentials and references.

Medical and worker’s compensation information will only be requested with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my perspective employer from a consumer-reporting agency. If so, I will be notified and given the name and address of the agency or the source, which provided the information. I acknowledge that facsimile (FAX), photographic copy or email shall be as valid as the original.

I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by One Source, The Background Check Company or its agent, to furnish the information described above. I understand that in the event a negative hiring decision is made based upon the results of my background check, a report will be furnished to me upon my request.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above mentioned information or reports.

PLEASE PRINT:

______

Last NameFirst NameMiddle Initial (Required)

______

OtherLEGALnames you have used, includingMAIDENname(s):

______

Home Address

______

CityStateZip

Other addresses if less than 7 years at home address: (use back of sheet for additional addresses)

______

AddressCityStateZip

______

AddressCityStateZip

______

Social Security NumberDate of birth (Required)

______

Driver’s License #State of IssueName as it appears on license

______

SIGNATURE OF APPLICANT

Iowa DepartmentofHuman Services

Authorization for Releaseof Child and DependentAdultAbuseInformation

,orfaxto(515)564-4112,ormailtotheIowaDepartmentofHumanServices,CentralAbuseRegistry,P.O.Box4826,DesMoines,IA50305.

Pleasespecifywhichabuseregistryyouarerequestingbycheckingtheappropriateboxbelow:

ChildAbuseRegistryDependentAdultAbuseRegistryBoth

PleasespecifyyourpreferredmethodofresponsebycheckingaboxandcompletingtheinformationinSection1.

The Riverside Community School District does not discriminate on the basis of race, color, religion, creed, sex, age, national origin, sexual orientation, gender identity, marital status, or disability in its educational programs and activities and does not discriminate on the basis of race, color, religion, creed, age, sex, national origin, sexual orientation, gender identity, marital status, or disability in its employment practices, or as otherwise prohibited by statute or regulation. For more information or concerns regarding educational programs or activities, employment practices or information regarding the grievance procedure, contact Dr. Timothy Mitchell, Equity Coordinator, RiversideCommunitySchool District, 330 Pleasant Street, PO Box 218, Carson, IA51525, 712-484-2212.

Riverside Community School District

Application for Employment

AddressFaxEmail

Name of Requesting Organization ______

Copy1: Central RegistryCopy2: Returned to Requester

LEGAL PROVISIONSFOR HANDLING

CHILD AND DEPENDENT ADULT ABUSEINFORMATION

Redissemination ofChild and DependentAdultAbuse Information (Iowa Code sections 235A.17 and 235B.8)

A person,agency,orotherrecipientofchild ordependentadultabuse information shall notredisseminate (release)thisinformation,exceptthatredissemination ispermitted when ALLofthe followingconditionsapply:

The redissemination isforofficial purposesin connection with prescribed dutiesor,in the case ofa health practitioner,pursuantto professional responsibilities.

The person to whomsuchinformation would be redisseminated would have independentaccess to the same information underIowa Code sections235A.15or235B.6.

A written record ismade ofthe redissemination,includingthe name ofthe recipientand the date and purpose ofthe redissemination.

The written record isforwarded to the Central Abuse Registrywithin 30 daysofthe redissemination.

CriminalPenalties (Iowa Code sections 235A.21and 235B.12)

A person isguiltyofa criminal offense when the person:

Willfullyrequests,obtains,orseeks to obtain childordependentadultabuse information underfalse pretenses,or

Willfullycommunicatesorseeks to communicate child ordependentadultabuse information to anyagency orperson exceptin accordance with Iowa Code sections235A.15,235A.17,235B.6,and 235B.8,or

Isconnected with anyresearch authorized pursuantto Iowa Code sections235A.15and 235B.6and willfullyfalsifieschildordependentadultabuse information oranyrecordsrelatingto child ordependent adultabuse.

Upon conviction foreach offense,the person isguiltyofa seriousmisdemeanorpunishablebya fine or imprisonment.

Anyperson who knowingly,butwithoutcriminal purposes,communicatesorseeks to communicate child or dependentadultabuse information exceptin accordance with Iowa Code sections235A.15,235A.17,235B.6, and 235B.8 isguiltyofa simple misdemeanorpunishable,upon conviction foreach offense,bya fine or imprisonment.

Anyreasonable groundsforbeliefthata person hasviolated anyprovision ofIowa Code Chapters235A or 235B shall be groundsforthe immediate withdrawal ofanyauthorized access thatperson mightotherwise have to childordependentadultabuse information.

470-3301 (Rev.2/16)