This Application Will Remain on File for Six Months

Rev. 1/6/05

This application will remain on file for six months.

FOOD SERVICE

Muscatine Community School District 2900 Mulberry Avenue - Muscatine IA 52761

Name: SS#:

Street: City:

State: Zip:

Home Phone: ( ) Work Phone: ( )

EMPLOYMENT RECORD (List last employer first) Reason for Dates Employer and Address Duties Leaving

REFERENCES

Name Address Position Phone

EDUCATION Degree or Highest Grade Name and address Completed High School College Trade School

The Muscatine Community School District is an Equal Opportunity Employer Check those areas in which you have experience, special interest or talent:

Supervision Purchasing/ordering Commercial baking Commercial cooking Salad/sandwich preparation Commercial dishwasher Commercial mixer Steam equipment Slicers Convection oven Cash register Recordkeeping Computers (specify Apple/DOS/Both)

Check your preferences:

Full time Split shift Breakfast Part time Lunch Van driver Elementary school Middle school High school Any facility

Van Driver Applicants: Chauffeur’s license #

Are you willing to work on a substitute basis? Yes No

What is the earliest time of the day you could report for work?

When would you be able to begin work?

Additional information that will be helpful in considering you as an applicant:

Have you ever been convicted of a felony?

Are you able to perform the essential duties of the job with or without a reasonable accommodation?

A physical exam and a police records check may be required at the time of employment.

I hereby certify, under penalty of immediate dismissal, that all of the statements provided are true and correct and authorize the district to contact previous and present employers.

Signature: Date: ______

It is the policy of the Muscatine Community School District not to discriminate on the bases of race, creed, color, gender, marital status, parental status, sexual orientation, gender identity, national origin, religion, age, veteran status or disability in its educational programs, activities, or employment practices. If you believe you have been discriminated against or treated unjustly, please contact Equity Director(s) Perry Rodocker, 621 Kindler Ave, 263-9049, or Wes Fowler, 2900 Mulberry Ave, 263-7223, Civil Rights Compliance Officer Roberta Swanson, 2705 Cedar Street, 263-6141, Affirmative Action Coordinate Wes Fowler, 2900 Mulberry Ave, 263-7223, or the 504 Coordinator Jan Collinson, 2900 Mulberry Ave, 263-7223. They will discuss the situation with you and if you wish help you file a grievance.