F Please Respond to the Following Questions

PERSONAL INFORMATION

Name: Date: Present Address: Home Phone: City, State, Zip: Cell Phone: Permanent Address: Work Phone: City State, Zip: Email: Position Desired: EDUCATION

High School Graduation Date: Name of High School: High School Equivalency Certificate (GED) – Date Awarded: State Awarding: A high school diploma or equivalent is required to work for Smyth County Schools College or Other Training Dates of Attendance Diploma, Degree or Course or Specialty From To Certificate

WORK EXPERIENCE Name of Employer Address & Phone Supervisor Position Held Dates

f Please respond to the following questions:

Questions: YES NO 1. Have you ever been charged with or convicted of a violation of the law other than a minor traffic violation? If yes, please explain:

2. Have you ever been discharged or requested to resign from a former position? If yes, please explain:

3. Is any complaint of child abuse or neglect against you pending or under investigation or has any such complaint ever been determined to be founded? If yes, please explain:

4. Are any criminal charges or proceedings pending against you? If yes, please explain:

5. For the purpose of the Immigration Reform and Control Act, are you legally eligible for employment in the United States? 6. Can you perform the essential functions of this position, with or without reasonable accommodations? 7. Have you resigned your current position? 8. Why are you leaving?

9. What is your present salary? 10. What is your desired annual salary? 11. How many unscheduled days off did you take last year? 12. When can you begin work?

If you are applying for a school bus driver’s position, please answer the following four questions:

Questions: YES NO 1. Do you have a CDL issued in VA? 2. Do you have a school bus driver’s license? 3. Have you been convicted of two or more traffic violations within the last 12 months? 4. In the last three years, were you subject to drug testing in a job designated as a “safety sensitive function in any Department of Transportation regulated mode subject to drug and controlled substance testing requirements”?

My signature below authorizes the school division to conduct a background investigation and authorizes release of information in connection with my application for employment. This investigation may include such information as criminal or civil convictions, driving records, previous employers and educational institutions, personal references, professional references, and other sources deemed appropriate in the sole discretion of the school division. I waive my right of access to any such information, and with limitation, hereby release the school division and the reference source from any liability in connection with its release or use. This release includes the sources cited above and illustrative examples as follows: the local Sheriff, information from the Central Criminal Records Exchange of either data on all criminal convictions or certification that no data on criminal convictions are maintained, information from the Virginia or other State Department of Social Service Child Protective Services Unit and any Locality to which they may refer for release of information pertaining to any findings of child abuse or neglect investigations involving me.

Furthermore, I unconditionally certify that I have made true, correct, and complete answers and statements on this application in the knowledge that they may be relied upon in considering my application. I acknowledge that these questions shall be continuing in nature, and I have a duty to update, change or further amplify my answers to guarantee accuracy at all times. I understand that any omission, misleading or falsely answered statement made or implied by me on this application, or any supplement to it, whether written or oral, will be sufficient grounds for failure to employ or for my immediate discharge should I become employed with the school division. In the event the School Board determines, in its sole discretion, the existence of a material adverse report or omission as to any information, I agree that the employment offer/appointment may be revoked immediately without further action, notice, or process. In conclusion, I acknowledge that if accepted for employment, I hereby agree to abide by the policies, regulations, and directives of the School Division. Date ______Signature of Applicant ______You may attach a resume or any other pertinent information that would help us evaluate your application.

Smyth County Public Schools is an equal opportunity employer, committed to non-discrimination in recruitment, selection, hiring, pay, promotion, retention or other personnel actions affecting employees or candidates for employment. Therefore, discrimination in employment against any person on the basis of race, color, religion, national origin, political affiliation, sex, gender, age, genetic information or disability is prohibited. Personnel decision shall be based on merit and the ability to perform the essential functions of the job, with or without reasonable accommodation. The following person has been designated to handle inquiries regarding the non-discrimination policies including Title IX, age, and racial discrimination: Director of Human Resources, 121 Bagley Circle, Suite 300, Marion, VA 24354 (276) 783-3791. The following person has been designated to handle inquiries regarding disability issues under Section 504 of the Rehabilitation Act and the Americans with Disabilities Act: Director of Special Education, 121 Bagley Circle, Suite 300, Marion, VA 24354, (276) 783-3791

References: Name Title Address Phone Relationship