Date:  ______________________

 

Southgate Independent School

William Blatt and Evergreen Avenue

Southgate, Ky  41071

(859)-441-0743

CLASSIFIED POSITION APPLICATION

 

Employee Information and Application Form

 

Name:  ______________________________ ___________

             (Last)               (First)                  (MI)

 

Telephone Number:  ___________________  S.S. Number:  ____________

 

Present Address:  _______________________________________________

                             (Street)                           (City)                              (Zip)

                            

Type of Position Desired:  ________________________________________

 

 

 

 

Educational and Professional Training

                  

 

School or Institution

Degree or Number of Credits

Year of Graduation

 

High School

 

 

 

 

College

 

 

 

 

College

 

 

 

 

College

 

 

 

 

College

 

 

 

 

Graduate School

 

 

 

 

 

Work Experience

 

Name of Place of Employment

Location

Job

Dates

Name of Immediate Supervisor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you presently under contract?  _____  If yes, where?  _______________

 

Have you ever been employed in another Kentucky school district? 

Yes _____ No_____ If yes, when and where? 

 

_____________________________________________________________

 

Have you ever had a contract for school employment by another school district not renewed?  Yes_____ No_____ If yes, when, where, and why?

_______________________________________________________________________________________________________________________________________________________________________________________

 

Please describe any extra activities you are able and willing to direct or supervise.

 

 

 

 

 

 

References

(Give three references, including supervisors that you have worked for)

 

Name

Phone Number

Position

 

 

 

 

 

 

 

 

 

 

 

Have you ever been convicted of a crime? (Other than minor traffic violations)  Yes ____ No____  If yes, attach explanation.

 

Applicant’s Authorization for Release of Information

(Read carefully before signing)

 

All information provided by me in support of my application for employment is true and correct to the best of my knowledge.  I understand that misrepresentations or omissions may be cause for rejection or may be cause for subsequent dismissal if I am hired.

 

I authorize this district to conduct a background investigation and authorize the release of information in connection with my application for employment.  This investigation may include such information as criminal or civil convictions, previous employers and educational institutions, personal references, professional references, and other appropriate sources.  I waive my right to access to such information and without limitation hereby release this district and the reference source from any liability in connection with its release or use.

 

FOR THIS TYPE OF EMPLOYMENT, STATE LAW REQUIRES A NATIONAL AND STATE CRIMINAL HISTORY BACKGROUND CHECK AS A CONDITION OF EMPLOYMENT.  THIS DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER ON THIS APPLICATION IS MANDATORY PURSUANT TO KENTUCKY REVISED STATUTE 160.380 AND KENTUCKY STATE POLICE REQUIREMENTS.  YOUR SOCIAL SECURITY NUMBER WILL BE USED FOR PURPOSES OF CRIMINAL BACKGROUND CHECKS AND ANY OTHER PURPOSES OF CRIMINAL BACKGROUND CHECKS AND ANY OTHER PURPOSE REQUIRED BY FEDERAL LAW.

 

____________________                                            _____________________________ 

Date                                                                             Signature    

 

The Southgate Independent School District provides equal employment opportunities to all people without regard to race, color, age, national origin, gender, religion or disability.