Wakefield Public Schools Office of the Superintendent 60 Farm Street Wakefield, MA 01880

Application for School Traffic Supervisor ________________________________________________________________________ Name_________________________________________________________________ Last First Middle Address______________________________________________________________ Are you a U.S. citizen or otherwise legally authorized to work in the United States Yes________No________ Telephone number (Home)-( _)____________(Work)-( )________________ Physical condition: Are you capable of performing the functions of this position? Yes_____No_____ State condition of Hearing__________Eyes_____ Length of residence in this town_________________________________ Do you possess a valid driver’s license______________ Have you an automobile at your disposal during school hours_______________________________________________________ Have you ever been convicted of a felony Yes_____No_____ If Yes, please explain_____________________________________________________ _______________________________________________________________________ Have you ever been convicted of a misdemeanor within the last five years? Yes_____No_____ If yes, please explain______________________________________________________ ________________________________________________________________________ (You may omit first convictions for drunkenness, simple assault, speeding, minor traffic violations, affray or disturbance of the peace, or any other offense within the last five years.)

Recognizing the confidential and sensitive nature of the information involved, only the Superintendent/Director of Human Resources and their confidential/executive secretaries shall have access to such data and only to the extent such information is

needed for the performance of his/her duties as follows: for the purpose of considering and making decisions for retention of current or hiring of prospective employees I HEREBY CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, MY ANSWERS TO ALL ITEMS ON THIS PAGE ARE TRUE AND CORRECT. Signature_________________________________ Date______________________________________

The Wakefield Public Schools does not discriminate on the basis of race, color or national origin, sex, age, sexual orientation, religion or disability. .