LYNNVILLE-SULLY COMMUNITY SCHOOL SULLY, IOWA 50251 EMPLOYMENT APPLICATION FORM The Lynnville-Sully Community School District is an Equal Opportunity Employer. In employing school district personnel, the board shall consider the qualifications, credentials, and records of the applicants without regard to race, color, creed, sex, marital status, national origin, religion, age, or disability. DATE: _______________________ POSITION FOR WHICH YOU ARE APPLYING: ______________________________ I.

NAME:___________________________________________________________ ADDRESS: _______________________________________________________ _______________________________________________________ TELEPHONE NUMBER: _____________________________

II.

EDUCATION______________________________________________________ (High School) Address DATE OF GRADUATION_____________ _____________________________________________________ (College) Address DATE OF GRADUATION______________

III.

COURSES BEYOND HIGH SCHOOL AND/OR WORK EXPERIENCES BEYOND HIGH SCHOOL THAT WOULD BE HELPFUL IN THE JOB FOR WHICH YOU ARE APPLYING? (SUPPORT STAFF ONLY)

IV.

WORK EXPERIENCE COMPANY

V.

ADDRESS

DATES OF EMPLOYMENT

LEFT JOB

REFERENCES: NAME

ADDRESS

STATE IN WHAT CAPACITY THIS PERSON KNOWS YOU

VI.

PLEASE STATE IN A FEW SENTENCES WHY YOU ARE APPLYING FOR THIS POSITION AND WHY YOU THINK YOU CAN BE SUCCESSFUL IN THIS POSITION.

VII.

PROFESSIONAL MEMBERSHIPS AND OFFICES HELD

VIII.

OTHER HONORS, AWARDS, OR ACCOMPLISHMENTS:

IX.

SERVICE RECORD HAVE YOU SERVED IN THE UNITED STATES MILITARY? ____YES____NO DISCHARGE STATUS: HONORABLE_________ OTHER_______

X.

ARE YOU CURRENTLY UNDER CONTRACT WITH ANOTHER EMPLOYER? _______YES _______NO

XI.

HAS THE POSSIBILITY OF ANOTHER JOB BEEN DISCUSSED WITH YOUR PRESENT EMPLOYER? ________YES _______NO

XII.

HAVE YOU EVER BEEN CONVICTED OF A VIOLATION OF LAW OTHER THAN A MINOR TRAFFIC VIOLATION? _______YES _______NO IF YES, PLEASE EXPAIN

XIII.

HAVE YOU EVER BEEN RELEASED FROM A JOB FOR USE OF DRUGS OR ALCOHOL? ________YES ________NO

XIV. ARE YOU ON A SEX OFFENDER REGISTRY? _______YES _______NO XV.

ARE YOU ON THE DEPARTMENT OF HUMAN SERVICES CHILD ABUSE REGISTRY? _______YES ______NO

XVI. ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW WHEN CONSIDERING THIS APPLICATION

I hereby certify that the statements made by me in this application and all related information which I have provided are true, accurate, and complete to the best of my knowledge. I understand that if I provide any false, inaccurate, or incomplete information, I will not be eligible for employment, or, if I am hired, I will be subject to disciplinary action or dismissal regardless of the date on which the District discovers the violations of its policy regarding application form dishonesty. I understand that if I apply for employment with the School District, the District may conduct a check of my criminal, credit, and/or driver’s license history. I agree to sign a Waiver authorizing the District to obtain a check of my criminal, credit, and/or driver’s license history check. RETURN APPLICATION TO SUPT. OF SCHOOLS

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