The Jay School Corporation Application for Employment

1976 W Tyson Road, PO Box 1239, Portland, IN 47371

(Pre-Employment Questionnaire) (An Equal Opportunity Employer)

Personal Information Date: ______

Name: ______Social Security #______

Last (Maiden)FirstMiddle (Optional)

Present Address ______

StreetCityState Zip

Phone Number ______Are you 18 years or older? ______yes ______no

Employment Desired

Position: ______Date you can start: ______Salary Desired: ______

Are you employed now? ____yes ____no If yes, may we inquire of your present employer? ____yes ____no

Have you ever applied at Jay School Corporation before? ____yes ____no If yes, when? ______

Education

/ Name & Location of School / Years Attended / Date Graduated
High School
College
Trade, Business, or Correspondence School

Recipient of the Indiana Work Ethic Certification_____ YES_____ NO (Available after May 2006)

References: (Give below the names of two persons not related to you, whom you have known at least one year.)

Name / Address & Phone Numbers / Business / Years Acquainted

In case of an emergency, notify: ______

Name AddressPhone Number

Relationship to the above: ______

Previous Employers: List below your previous employers, starting with the most current first.

1. Employer & Phone # / Dates : / Work Performed
Address / From - To
Job Title
Supervisor / Hourly Rate / Salary
Reason for Leaving / Starting Final
2. Employer & Phone # / Dates: / Work Performed
Address / From - To
Job Title
Supervisor / Hourly Rate / Salary
Reason for Leaving / Starting Final
3. Employer & Phone # / Dates: / Work Performed
Address / From - To
Job Title
Supervisor / Hourly Rate / Salary
Reason for Leaving / Starting Final
4. Employer & Phone # / Dates: / Work Performed
Address / From - To
Job Title
Supervisor / Hourly Rate / Salary
Reason for Leaving / Starting Final

Request for Background Information

Jobs with Jay School Corporation involve contact with our student population. Complete questions below to help us evaluate your suitability to work with students. All applicants for employment are expected to provide us with background information; you are not being singled out from other applicants for closer inspection. These questions are a part of the application and any misrepresentation or omission of facts may be grounds for disqualification from further consideration or for termination from employment regardless of when the misrepresentation or omission is discovered.

Conviction of a crime or any affirmative answer provided by you is not an automatic bar to employment. The Jay School Corporation will consider the nature of any conviction or alleged conduct underlying an affirmative response, the date of the alleged conduct in question, your intervening conduct, the relationship between an offense or alleged conduct underlying an affirmative response, and the position for which you are applying. If you answered yes to any of the following questions, explain the circumstances of each on a separate sheet and attach it to this application.

If you are now working, is your conduct as an employee or the quality of your work the focus of any investigation by your current employer? ____yes ____no
Have you ever resigned from a job after being disciplined by your employer or after being offered the opportunity to resign rather than be terminated? ____yes ____no
Have you ever been investigated for, charged with, or plead guilty or “no contest” to any crime involving the sexual abuse of any person or indecency with a minor? ____yes ____no
Have you ever been convicted of or plead guilty to a crime, offense or infraction (including traffic infractions or offenses), other than those described in 3 above, that have not been expunged by a court or placed under seal?

____yes____no

Have you ever been charged with a crime, where the court has deferred further proceedings without entering a finding of guilt? ____yes ____no

Authorization and Release

I authorize the administration of The Jay School Corporation to check my employment history, including without limitation, reference checks. Additionally, I waive in connection with any request for, or provision of such information, any claims, causes or actions, including without limitation, defamation, infliction or emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the school corporation, its officials, employees, trustees, or agents, or against any provider of such information. I have read this authorization and release of all claims, and I expressly agree to the terms set out herein.

I understand that if employed: 1) any misrepresentation or omission of facts requested in the application is cause for dismissal and 2) If employment is for no definite period that I may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.

Signature ______Date ______

Revised 9/2013

The Jay School Corporation

1976 W Tyson Rd ● P O Box 1239 ● Portland, Indiana 47371

Phone (260) 726-9341 ● Fax (260) 726-4959

Police Record Release Form

Applicant to Complete

We request the following record check on:

(please print)

Name:______

First Middle Maiden Last

Date of Birth ______Social Security # ______

Address ______Phone # ______

Home

______Phone # ______

Cell

______

I hereby submit this written authorization to release to The Jay School Corporation any police and/or court records including convictions which directly or indirectly involve me, except those involving a crime that has been expunged by a court or placed under seal. I agree to let the above see and have copies of these records if so desired (by paying any required copying fees). I hereby release your employees and the Police/Sheriff Department from any and all liabilities for any damages whatsoever which might result from furnishing the JSC with such records.

Signature: ______

To be completed by Local Police Department:

I certify that a police record check was made on the person listed above at the

______County Sheriff Department and

______No record was found to exist.

______A record exists and copies are following.

Name of verifying official ______Title ______

Signature of verifying official ______Date______

Revised: 9/2016

Jay

Jeremy Gulley, SuperintendentBrad DeRome, Business Manager/Treasurer

Trent Paxson, Ed.S., Director of Curriculum & InstructionAnn Van Horn, Special Education Director