Pre Employment Application

PRE EMPLOYMENT APPLICATION

PERSONAL INFORMATION

First Name

Middle Name

Last Name

List Any Other Names Used

Address

Mailing Address

City

State

Zip Code

Home Phone

Cell Phone Number

Email Address

Emergency Contact Name

Contact Number

Relationship

PREFERENCE

Position(s) for wich you are applying

Employment Desired

Full-Time

Part-Time

Temporary

Grade/Subject Preference

LANGUAGE

Foreign Language Ability

Do you have certification of bilingual proficiency?

Yes

Speak

Fluently

Some

None

Credential

Read/Write

Fluently

Some

None

Other languages you speak fluently

EDUCATION UNDERGRADUATE/GRADUATE

Official transcript of college and university work required upon hire.

1. Education Undergraduate/Graduate

From

Degrees Earned

Major

Minor

2. Add More Education Undergraduate/Graduate

Add More Education Undergraduate/Graduate

2. Education Undergraduate/Graduate

From

Degrees Earned

Major

Minor

3. Add More Education Undergraduate/Graduate

Add More Education Undergraduate/Graduate

3. Education Undergraduate/Graduate

From

Degrees Earned

Major

Minor

Number of semester units of upper division/graduate work after receipt of BA or BS degree

Official transcript of college and university work required upon hire.

Master’s Degree

Yes

Doctorate

Yes

Graduate GPA

Scholastic Honors

Other Honors of Distinction

Scholastic Averages of Undergraduate Work

A-

B-

C-

EQUAL OPPORTUNITY EMPLOYER. It is our policy to abide by all Federal and State laws prohibiting employment discrimination solely on the basis of a person’s race, color, creed, national origin, religion, age, sex, marital status or physical or mental disability, except where a reasonable, bona fide occupational qualification exist.

STUDENT TEACHING/INTERN EXPERIENCE

Include only experience applicable to position for which you are applying. List the most recent first.

1. District/School

City/State

From

Grades/Subjects

Principal

2. Add More Student Teaching/Intern Experience

Add More Student Teaching/Intern Experience

2. District/School

City/State

From

Grades/Subjects

Principal

TEACHING SERVICE UNDER CONTRACT

Include part-time if contracted (Do not list substitute teaching experiences.)

1. District/School

City/State

From

Grades/Subjects

Supervisor

Reason for leaving

2. Add More Teaching Service Under Contract

Add More Teaching Service Under Contract

2. District/School

City/State

From

Grades/Subjects

Supervisor

Reason for leaving

OTHER WORK EXPERIENCE

1. Name of Employer

City/State

From

Type of Work

Supervisor

2. Add More Work Experience

Add More Work Experience

2. Name of Employer

City/State

From

Type of Work

Supervisor

3. Add More Work Experience

Add More Work Experience

3. Name of Employer

City/State

From

Type of Work

Supervisor

REFERENCES

1. Reference

Name

Relationship

Phone Number

Email Address

2. Add More Reference

Add More Reference

2. Reference

Name

Relationship

Phone Number

Email Address

3. Add More Reference

Add More Reference

3. Reference

Name

Relationship

Phone Number

Email Address

AREAS OF SPECIALIZATION

PRE-EMPLOYMENT AFFIDAVIT

Please answer the following questions. While a “yes” answer will not necessarily disqualify you from consideration, it is necessary to explain the circumstances in writing.

Have you ever been discharged from employment and/or resigned to avoid discharge?

Yes

Employer’s name

From

Have you ever had a credential suspended or revoked?

Yes

Date

Location

Why

Have you ever been convicted or charged of a crime for an offense other than a minor traffic violation?

Yes

(Please note: A conviction is not an automatic bar to employment. Each case is considered on its individual merits. Failure to disclose criminal activity will disqualify you from employment.)

1. Date Charged/Convicted

City & State

Felony or Misdemeanor

Describe Nature of Offense

2. Add More

Add More

2. Date Charged/Convicted

City & State

Felony or Misdemeanor

Describe Nature of Offense

3. Add More

Add More

3. Date Charged/Convicted

City & State

Felony or Misdemeanor

Describe Nature of Offense

Disclaimer and Signature of Applicant

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 falsified information or significant omissions may disqualify me from further consideration for employment and may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. Initial

I authorize all persons listed above (and on the accompanying resume, if any) to give Amigos Por Vida-Friends for Life Public Charter School any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise, and release all parties, such persons and Amigos Por Vida-Friends for Life Public Charter School, from liability for any damage that may result from furnishing same to Amigos Por Vida-Friends for Life Public Charter School. Initial

If employed by Amigos Por Vida-Friends for Life Public Charter School, I agree to conform to the rules and regulations of Amigos Por Vida-Friends for Life Public Charter School. I further understand that my employment can be terminated, with or without cause of notice, at any time, at the discretion of either Amigos Por Vida- Friends for Life Charter School or myself. I further understand that no manager or representative of Amigos Por Vida-Friends for Life Public Charter School, other than the president of Amigos Por Vida-Friends for Life Public Charter School, has any authority to enter into any agreement, oral or written, for employment for any specified period of time or to make any assurance or promise of continued employment. Initial

I understand and agree that I may be required to take a drug and alcohol screening test as part of the pre-employment and at any time during my employment. I hereby give my voluntary consent for a blood and/or urine sample to be collected from me and submitted for testing. I also consent to the release of the test result to Amigos Por Vida-Friends for Life Public Charter School for its use. I understand that any positive drug or alcohol result may preclude my employment. Initial

I authorize Amigos por Vida-Friends for Life Public Charter School to obtain a criminal / background check as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for Vida-Friends for Life Public Charter School to procure criminal/ background checks at any time during my employment period. Initial

Signature

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