St. Croix Central School District

Support Staff ST. CROIX CENTRAL SCHOOL DISTRICT EMPLOYMENT APPLICATION Please Print Date: Name: Last First Middle

Address: Street (Area Code) Telephone

City State Zip Code Position Applied for: Grade Level/ Subject Area 1st Choice 2nd Choice (Area Code) Cell Telephone E-mail Address: Have you filed an application with our district before? Yes No If “Yes” give date and position applied for: Are you presently under contract with any school district? Yes No EDUCATIONAL BACKGROUND

DIPLOMAS, Grade Point Major / Minor DEGREES OR Average School or Institution and Location CREDITS EARNED (GPA) HIGH SCHOOL TECHNICAL SCHOOL COLLEGE/UNIVERSITY EXPERIENCE LIST ALL PREVIOUS EMPLOYMENT STARTING WITH PRESENT OR MOST RECENT. USE A SEPARATE SHEET OF PAPER IF NECESSARY. Dates Name of Employer and Address Your Title From

To (Area Code) Telephone: Work Performed: Reason for Leaving:

Supervisor: Number of Yrs: Dates Name of Employer and Address Your Title From

To (Area Code) Telephone: Work Performed: Reason for Leaving:

Supervisor: Number of Yrs: Dates Name of Employer and Address Your Title From

To (Area Code) Telephone: Work Performed: Reason for Leaving: Support Staff Supervisor: Number of Yrs:

CanPlease we list contact activities the that people you arelisted qualified above? to supervise or coach: Yes No

REFERENCES Name Position Address Telephone

OTHER QUALIFICATIONS Summarize special job-related skills and qualifications acquired from employment or other experiences (including U.S. military service) and/or state any additional information you feel may be helpful in considering your application, i.e. honors, awards, activities, technology skills or professional development activities:

Is there a criminal charge, felony or misdemeanor, currently pending against you? Yes No If you checked “yes”, please give a brief explanation.

Have you ever been convicted of a crime, felony or misdemeanor? Yes No If you checked “yes”, please give a brief explanation.

Are you subject to any visa or immigration status, which would prevent lawful Yes No employment?

Conviction of a crime or arrest is not an automatic bar to employment. The District will consider the nature of the offense, the date of the offense, and the relationship between the offense and the position for which you are applying.

______SIGNATURE OF APPLICANT DATE

Acceptance, retention or review of the application for employment by the District does not guarantee that an applicant will be offered a job. Any misrepresentation or willful omission of facts by the applicant on this application will constitute sufficient cause to disqualify the applicant or terminate the applicant’s employment. I hereby authorize the District to conduct work history and personal reference inquiries to determine my acceptability for employment.

______Support Staff SIGNATURE OF APPLICANT DATE