<p> ______</p><p>Iowa Educational Services for the Blind and Visually Impaired Iowa Braille School </p><p>A Board of Regents, State of Iowa Program</p><p>APPLICATION FOR EMPLOYMENT</p><p>Complete this application in detail. Incomplete applications may be returned or may result in disqualification or a lower score rating. All applications are retained in an active file for a period of one year.</p><p>Direct Questions to: Justin Ruegg, Director of Human Resources 1002 G Avenue Vinton, Iowa 52349 Phone: 319-472-5221, ext. 1226 Phone: 800-645-4579, ext. 1226 Fax: 319-472-4371 [email protected]</p><p> www.iowa-braille.k12.ia.us</p><p>Our mission is to enable Iowa's students who are blind or visually impaired to function as independently as possible in all aspects of life by providing appropriate educational opportunities, resources, and support services. . Personnel; Forms; App 2010 Office use, date received ______IESBVI / Iowa Braille School Attn: Human Resources 1002 G Avenue Vinton, Iowa 52349 A Board of Regents, State of Iowa Program</p><p>APPLICATION FOR EMPLOYMENT Complete this application in detail. Incomplete applications may be returned or may result in disqualification or a lower score rating. All applications are retained in an active file for a period of one year. </p><p>GENERAL INFORMATION (Please Print or Type)</p><p>Name ______Today’s Date ______(Last) (First) (Middle Initial)</p><p>Address ______Phone: Home (___)____-_____ Work (___)____-______</p><p>Cell Phone ______</p><p>______City State Zip Code e-mail</p><p>Are you a former employee of IBSSS? _____ </p><p>EMPLOYMENT AND WORK SCHEDULE DESIRED Position for which you are applying: (You may list up to three. Be specific.) </p><p>1. ______2. ______3. ______</p><p>Date you would be available to begin work: ______Please check work schedule preferences: 1. Full-time ______Part-time ______Substitute _____</p><p>2. All year______School year ______Summer _____ </p><p>3. Days ______Evenings ______Nights (11 - 7) ______Weekends _____</p><p>4. Number areas of the state in preferred order to work, #1 being the most preferred and number all, 1-5: Northeast Iowa _____ Southeast Iowa _____ Southwest Iowa _____ Northwest Iowa ______</p><p>Central Iowa ______</p><p>REQUIRED INFORMATION Have you ever been known by any other name(s) which will be required to verify any of the information in this application (e.g. maiden name, alias)? ____Yes ____No If yes, give name(s): ______</p><p>Do you have a valid U.S. Driver's license? Yes____ No____ State:______CDL? Yes____ No____</p><p>Have you ever been convicted of a crime in this state or any other state? Yes____ No____ </p><p>If yes, state nature of offense and state: ______</p><p>Do you have a record of founded child or dependent adult abuse? Yes____ No____ </p><p>If yes, state nature of offense and state: ______2 SPECIAL CERTIFICATIONS OR LICENSES If a license or certification is required to practice a trade or profession for which you are applying, complete the following: </p><p>Name of Trade or Profession ______License Number ______</p><p>Issued By ______Expiration Date ______</p><p>Teachers: Endorsements/Approvals: ______</p><p>If you are applying for a teaching position, attach a copy of your current teaching certificate. </p><p>EDUCATION RECORD</p><p>Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 GED, College 1 2 3 4 5 6 7 8</p><p>Are you working toward a degree? Yes _____ No ______If yes, what degree? ______Major ______Minor ______Anticipated completion date ______</p><p>Schools attended beyond high school: Name ______Location ______Total credit hours completed ______Quarter hrs.?______Semester hrs.?______Field of study/area of concentration: Major ______Minor ______Degree obtained (i.e. AA; BA; MA): ______</p><p>Name ______Location ______Total credit hours completed ______Quarter hrs.?______Semester hrs.?______Field of study/area of concentration: Major ______Minor ______Degree obtained (i.e. AA; BA; MA): ______</p><p>Name ______Location ______Credit received ______Quarter hrs.? ______Semester hrs.? ______Field of study/area of concentration: Major ______Hrs. _____ Minor _____ Hrs. _____ Degree obtained (i.e. AA; BA; MA): ______</p><p>Name ______Location ______Credit received ______Quarter hrs.? ______Semester hrs.? ______Field of study/area of concentration: Major ______Hrs. ______Minor ______Hrs. ______Degree obtained (i.e. AA; BA; MA): ______</p><p>3 EMPLOYMENT HISTORY Begin with most recent job. Use additional space / paper if necessary. Include the previous ten years.</p><p>(1) Current or most recent employer Company name/address ______Job Title ______Describe duties, equipment used: ______Date started ______Date left ______Rate of Pay ______Reason for leaving: ______Supervisor's name: ______Phone: ______May we contact? _____ Yes _____ No</p><p>(2) Previous employer Company name/address ______Job Title ______Describe duties, equipment used: ______Date started ______Date left ______Rate of Pay ______Reason for leaving: ______Supervisor's name: ______Phone: ______May we contact? _____ Yes _____ No</p><p>(3) Previous employer Company name/address ______Job Title ______Describe duties, equipment used: ______Date started ______Date left ______Rate of Pay ______Reason for leaving: ______Supervisor's name: ______Phone: ______May we contact? _____ Yes _____ No</p><p>(4) Previous employer Company name/address ______Job Title ______Describe duties, equipment used: ______Date started ______Date left ______Rate of Pay ______Reason for leaving: ______Supervisor's name: ______Phone: ______May we contact? _____ Yes _____ No</p><p>(5) Previous employer Company name/address ______Job Title ______Describe duties, equipment used: ______Date started ______Date left ______Rate of Pay ______Reason for leaving: ______Supervisor's name: ______Phone: ______May we contact? _____ Yes _____ No</p><p>4 REFERENCES Give the names of at least three people, other than friends or relatives, who are familiar with your work qualifications and who have known you at least one year. Applications with incomplete reference information will be disregarded.</p><p>1. Name/Profession ______Daytime phone ______Years known ______How does this individual know your work? ______</p><p>2. Name/Profession ______Daytime phone ______Years known ______How does this individual know your work? ______</p><p>3. Name/Profession ______Daytime phone ______Years known ______How does this individual know your work? ______</p><p>PLEASE READ BEFORE SIGNING</p><p>I CERTIFY that this application contains no willful misrepresentations and that the information is true and complete to the best of my knowledge. I understand that should investigation at any time disclose any misrepresentation, my application may be rejected, my name may be removed from consideration for employment, I may be dismissed from state service if employed, and I may be disqualified from applying for any other position. I also understand that, in compliance with Iowa Code Chapter 22, information on this application and any documents submitted to be included with the application are public records and will be available to the public upon request, except for information deemed confidential by the Statewide System for Vision Services / Iowa Braille and Sight Saving School, in accordance with applicable statutes. I understand that in signing the Application for Employment, I am consenting to any reasonable inquiry that may be necessary to verify the information I have provided on this form or may provide in conjunction with my application. I also understand that a check with the Iowa Child Abuse Registry and a criminal background check are performed as a condition of employment.</p><p>SIGN HERE IN INK: ______DATE: ______ADDITIONAL SPACE IF NEEDED</p><p>Equal Employment Opportunity and Treatment Qualified applicants are eligible to compete for all positions regardless of race, color, national origin, religion, sex, sexual orientation, gender identity, age, marital status and disability if the applicant with or without reasonable accommodation, is able to perform the essential functions of the position..</p><p>5 Optional Information</p><p>Equal Employment Opportunity Information Completing the Equal Employment Opportunity information is voluntary. The information is used to assist us in our affirmative action efforts in compliance with federal regulations. Refusal to submit this information will not adversely reflect on your application for employment. Thank you for your assistance.</p><p>NAME: ______</p><p>DATE: ______</p><p>POSITION FOR WHICH YOU ARE APPLYING: ______</p><p>RACE/ETHNICITY</p><p>______1. HISPANICS of any race; Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.</p><p>FOR NON-HISPANICS ONLY:</p><p>______2. AMERICAN INDIAN OR ALASKAN NATIVE: Persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.</p><p>______3. ASIAN: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent. This area includes, for example, China, Japan, and Korea.</p><p>______4. BLACK, OR AFRICAN AMERICAN: Persons having origins in any of the Black racial groups of Africa.</p><p>______5. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: Persons having origins in any of the original peoples of Pacific Islands. This area includes, for example, the Philippine Islands and Samoa.</p><p>______6. WHITE: Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.</p><p>______7. TWO OR MORE RACES</p><p>DISABLED PERSON: _____Yes _____ No SEX: _____ Male _____ Female</p><p>(over)</p><p>6 Optional Information</p><p>Veteran's Status </p><p>______Not a Veteran ______Veteran ______Disabled Veteran</p><p>If you are a veteran of the United States Armed Forces with an honorable discharge, you may qualify for veteran points. Upon presentation of Form DD214, the school gives veteran's preference points as required by law to qualified disabled veterans and veterans with an honorable discharge who served during specified periods. The periods are: 1. Persian Gulf Conflict Service, August 2, 1990 - no ending date yet established. 2. Lebanon, Grenada, and Panama, - based on award of Armed Forces Expeditionary medal 3. Vietnam Era - August 5, 1964 - May 7, 1975 4. Korea - June 25, 1950 - January 31, 1955 5. World War II - December 7, 1941 - December 31, 1946 </p><p>Applicants wishing to receive a 10-point preference based on a service-connected disability must submit a "10-Point Preference" letter issued by the Veterans Administration and dated within the last 12 months. Persons receiving a Purple Heart award must submit a copy of an official document from the Veterans Administration or Defense Department as proof to have 10 points added to their final score. </p><p>Persons who served on active duty for training purposes only, such as active reservists who served six months, are not eligible for veteran's preference unless they were discharged for a service-connected disability.</p><p>Veteran's Points (Merit Positions Only)</p><p>To claim five veteran's points, you must submit proof of service (such as DD-214) that includes the date of induction, date of honorable separation and social security number. This will be kept as long as you are an active applicant, so send a photocopy only. Veterans who wish to claim an additional five points for a service connected disability must also submit proof of disability from the Veteran's Administration dated within the last 12 months and then update it every 12 months thereafter to verify continued eligibility. If your name has been changed from that listed on your separation document, print it at the top of the document as it appears on this application. To be eligible for veteran's points, you must be a citizen and resident of Iowa. Do you now maintain a residence in Iowa? ______</p><p>Veteran's Preference Law (Code of Iowa - Chapter 70) (Non-Merit Positions Only)</p><p>Applicants who were honorably discharged from the military of the United States, were involved in any war which the United States was or is now engaged, and is a citizen and resident of the state of Iowa, shall be entitled to preference in appointment and employment over other applicants of no greater qualifications. Obligation of verification lies with the applicant. * * * * * * * * * * * * * *</p><p>How did you learn of this position opening?______(over)</p><p>7</p>