Check List:
FORMCHECKBOX Complete Application
FORMCHECKBOX Application Oath
FORMCHECKBOX References
FORMCHECKBOX Employer Check
FORMCHECKBOX Resume
FORMCHECKBOX Fingerprints
FORMCHECKBOX Pre-Interview
FORMCHECKBOX Interview
FOR OFFICE USE ONLY

Liberty School District J-4

Joes, Colorado

Position Preference(s)

Date you are available:

FORMCHECKBOX Check if you would like to be placed on our
substitute list.

Application for CLASSIFIED POSItion

PERSONAL INFORMATION

Last Name, First, Middle (Mr./Mrs./Ms)

Other names that files may be listed under

Street Address

City, State, Zip Code

Other Street Address if needed for future contact

City, State, Zip Code

Telephone Numbers

Home ( )

Work ( )

Social Security Number

Contact if you are not available:

Name

Phone Number ( )

E-mail Address

FOREIGN LANGUAGES

Please check level of proficiency in speaking, reading and writing.

Language:

Fair

Good

Excellent

Fair

Good

Excellent

Speaking

FORMCHECKBOX

Speaking

FORMCHECKBOX

Reading

FORMCHECKBOX

Reading

FORMCHECKBOX

Writing

FORMCHECKBOX

Writing

FORMCHECKBOX

DRIVING HISTORY

Do you have a valid Colorado Driver's License? _______yes _______no

Do you have a Commercial Driver's License? _______yes _______no

Driver's License Number

State

List all charged violations within the past 5 years

PHYSICAL IMPAIRMENT

Do you have any impairment: physical, mental, or medical which could interfere with your ability to perform the job for which you have applied? _____ yes _____ no

If Yes, please explain circumstances:

EMPLOYMENT HISTORY

Most Recent Employer

Are you currently working for this employer?

FORMCHECKBOX Yes

FORMCHECKBOX No

If yes, may we contact?

FORMCHECKBOX Yes

FORMCHECKBOX No

School/Company Name

City

State

Phone Number

Street Address

Dates Mo/Yr

Job Title

Supervisor

Salary

Reason for leaving

Second Most Recent Employer

School/Company Name

City

State

Phone Number

Street Address

Dates Mo/Yr

Job Title

Supervisor

Salary

Reason for leaving

Third Most Recent Employer

School/Company Name

City

State

Phone Number

Street Address

Dates Mo/Yr

Job Title

Supervisor

Salary

Reason for leaving

Fourth Most Recent Employer

School/Company Name

City

State

Phone Number

Street Address

Dates Mo/Yr

Job Title

Supervisor

Salary

Reason for leaving

Fifth Most Recent Employer

School/Company Name

City

State

Phone Number

Street Address

Dates Mo/Yr

Job Title

Supervisor

Salary

Reason for leaving

Education (List most recent first)

Name of College

or High School

Location

City and State

Dates

Of Attendance

Major

Type of Degree

Year of Graduation

M/yr

Extracurricular Activities (Indicate the number of years experience)

List professional growth activities any computer courses you have taken in the past three years. List the committees and task forces and roles in which you served.

Dates

Legal Information

1) Are you prevented from lawfully becoming employed in this country because of VISA or immigration status? (Proof of citizenship or immigration status will be required upon employment.)

FORMCHECKBOX Yes FORMCHECKBOX No

2) Have you been dismissed from any position for any immoral or unprofessional conduct or unfitness for services?

FORMCHECKBOX Yes FORMCHECKBOX No

3) Have you since the age of 18, ever been convicted of a misdemeanor or felony?

FORMCHECKBOX Yes FORMCHECKBOX No

Note: A conviction will not necessarily bar you from employment. Each conviction will be judged on its own merits with respect to time, circumstances, and seriousness. If any of the above statements have been answered yes, explain under General Comments.

Personal Statement

In your personal statement please address how you believe you fulfill our qualifications for this position. Please take special care to discuss any special training, talents, desire, skills, or knowledge you have that applies to this position. In addition, discuss any background in multicultural education and special education and any experiences working with diverse student populations. Any personal characteristics that make you more qualified may also be included.

General Comments Use this space for any additional comments from previous sections.

Referral Source:

FORMCHECKBOX Advertisement/Posting FORMCHECKBOX Employee/Friend FORMCHECKBOX Internet FORMCHECKBOX Other (explain below)

____________________________________________________________________________________________________________

I have read and understand the procedures and conditions of employment in Liberty School District J-4.

I understand that Liberty School District J-4 may conduct examinations into my background; I understand that reference checks will be made; I understand by affixing my signature below that I consent to such examination; I further understand that my signature certifies that all information in this application is true and correct; I understand that false statements on this application may result in termination of employment.

In the event that Liberty School District J-4 employs me, I agree to abide by all its applicable policies, procedures, rules, and regulations.

Signature Date

Thank you for applying to Liberty School District J-4. Our goal is to find the most qualified staff in order to prepare our students to meet the challenges of their own futures.

Liberty School District J-4

9332 Highway 36

P.O. Box 112

Joes, CO 80822

(970) 358-4288

Fax: (970) 358-4282

Pre-employment Verification

Classified/Certificated Employees

Applicant’s Oath

(Colorado Revised Statute 22-32-130)

Name (Last, First, Middle, Maiden) ______________________________________________________________________________

Social Security Number___________________ I have applied for the ___________________________________ position

I am the above listed applicant and I do hereby certify under penalty of perjury, either:

1. FORMCHECKBOX I HAVE NEVER BEEN convicted of committing a felony* or misdemeanor* (other than a misdemeanor traffic offense or traffic infraction).

2. FORMCHECKBOX I HAVE BEEN convicted** of committing a felony or misdemeanor (not including a misdemeanor traffic infraction). Information specifying a felony or misdemeanor for which I was convicted is as follows:

Convictions(s)____________________________________________________________________________________________

Court(s)__________________________________________________________________________________________________

Date(s)___________________________________________________________________________________________________

* A person is deemed to have been convicted of committing a felony or misdemeanor if such a person has been convicted under the laws of any other state, the United States, or any territory subject to the jurisdiction of the United States of an unlawful act, which, if committed within this state, would be a felony or misdemeanor.

** “Convicted” means a conviction by a jury or by a Court and shall also include the forfeiture of any bail, bond, or other security deposited to secure appearance by person charged with having committed a felony or misdemeanor, the payment of a fine, a plea of nolo contendere, and the imposition of a deferred or suspended sentence by the Court.

I hereby affirm that all information on and with this oath is true and complete. I understand that any misrepresentation of facts may result in my termination and that falsification of statements on and with this attestation may be punishable by law.

Signature of Applicant Date

(To be signed in the presence of a notary public)

SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF, 20

WITNESS MY HAND AND OFFICIAL SEAL.

MY COMMISSION EXPIRES

Notary

SEAL

Address

VOLUNTARY Equal Employment Opportunity Information

Dear Applicant:

In order to comply with the Department of Education’s request for information for the Office of Civil Rights, please complete the following information. This information is to be used for statistical purposes only and will be retained separately from the application.

Name_____________________________________________________________ Social Security Number ____________________

Address__________________________________________________________ Telephone Number ________________________

City_____________________________________________________ State______________ Zip Code _________________________

Date of Birth __________________________________

Position Applied for: __________________________________________________________________________________________

1. Sex:

FORMCHECKBOX Male FORMCHECKBOX Female

2. Veteran/U.S. Military Status:

FORMCHECKBOX Non-veteran

FORMCHECKBOX Pre-Vietnam Veteran

FORMCHECKBOX Pre-Vietnam with service incurred disability

FORMCHECKBOX Vietnam Era Veteran (8/5/64 – 5/7/75)

FORMCHECKBOX Vietnam Era Veteran with service incurred disability

FORMCHECKBOX Post Vietnam Era Veteran

FORMCHECKBOX Post Vietnam Era Veteran with service incurred disability

3. Ethnic Background:

FORMCHECKBOX White-origins in Europe, North Africa, or Middle East

FORMCHECKBOX Asian-origins in Far East, S.E. Asia, India or Pacific Islands

FORMCHECKBOX Black-origins in Africa

FORMCHECKBOX Hispanic-Mexican, Puerto Rican, Cuban, Central or South America

FORMCHECKBOX American Indian-origins in North America, to include Alaska

4. Physical Condition:

FORMCHECKBOX No Handicap

FORMCHECKBOX Physically Handicapped (No Facility Modifications needed)

FORMCHECKBOX Physically Handicapped (Facility Modifications needed)

FORMCHECKBOX Health Handicapped (Heart Attack, Diabetic, Seizures, etc.)

FORMCHECKBOX Mentally Handicapped (Learning Disabled)

5. Highest Degree of Education:

FORMCHECKBOX GED

FORMCHECKBOX High School Diploma

FORMCHECKBOX Associate Degree

FORMCHECKBOX Bachelor’s Degree

FORMCHECKBOX Master’s Degree

FORMCHECKBOX Specialist

FORMCHECKBOX Ed. D.

FORMCHECKBOX Ph. D.

Majoring area of highest degree: __________________________________________________________________________

Liberty School District J-4

9332 Highway 36

Joes, CO 80822

AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER