APPLICATION FOR EMPLOYMENT – CERTIFICATED
This application form will be used as a working
document by the screening committee.
Complete the entire form. If there
is insufficient space for an answer, attach an additional page with your name
on it and indicate which answer you are continuing. Please print or type your responses.
PERSONAL INFORMATION:
Last Name: First: Middle:
Home Address:
Home Phone: Fax: Email:
PRESENT EMPLOYMENT INFORMATION:
Present Position/Title:
Employer Name/Address:
Dates of employment:
Current annual salary:
Business phone: Fax: Email:
PREVIOUS EMPLOYMENT HISTORY: List other full-time experience in reverse
chronological order.
Position/Title Organization/Location Grade Level/Enrollment Dates
Do you have a Washington
State Teaching Certificate?
Other certificates (kind,
state, current or expired)
EDUCATION: List education in reverse chronological
order.
Institution Dates Attended Major/Minor Degrees
REFERENCES: List
the names of four persons who know of your professional work and
qualifications. Name Position Address Phone
Do you wish to place any
restrictions on contacting these and other references?
If yes, explain:
My signature below authorizes the school district to conduct a background investigation, including criminal convictions, driving records, previous employment, and personal references, as part of the application process. I hereby consent to the release all information related to this investigation, and release the school district from any liability in connection with the use of this information.
I hereby certify that the information contained in this application and otherwise provided by me as part of the application process is complete and true. I understand that any false or misleading information provided by me will constitute sufficient grounds for disqualification of my application, or in the event that I am employed by the district, for my dismissal.
Signature Date
APPLICATION INSTRUCTIONS:
Mail
letter of application, completed application form and resume to: Superintendent
305
Monumental Way
APPLICANT
DISCLOSURE FORM PURSUANT TO RCW 43.43.830. Answer YES or NO to each listed
item. If the answer is YES to any item,
explain in the area provided, indicating the charge or finding, the date, and
the court(s) involved. Pursuant to RCW
9A.72.085, I certify under penalty or perjury under the laws of the State of
1. Have you ever been convicted of any crimes against persons as defined in RCW 43.43.830 and listed as follows: Aggravated murder; first, second or third degree murder; first or second degree kidnapping; first, second or third degree assault; first, second or third degree rape; first, second or third degree statutory rape; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; malicious harassment; first, second or third degree child molestation; first or second degree sexual misconduct with a minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony; indecent exposure; or any of these crimes as they may be renamed in the future. ANSWER ______ If YES, explain below.
2. Have you ever been found in any dependency action under RCW 13.34.030(2)(b) to have sexually assaulted or exploited any minor or to have physically abused any minor. ANSWER ______ If YES, explain below.
3. Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor? ANSWER ______ If YES, explain below.
4. Have you ever been found in any disciplinary board final decision to have sexually abused or exploited any minor or to have physically abused any minor? ANSWER ______ If YES, explain below.
5. Have you ever been dismissed or asked to resign or had any disciplinary action against you from any employment or position? Yes _____ No_____ If yes, please provide details:
6. Have you ever resigned or left a job by mutual agreement following allegations of misconduct or unsatisfactory job performance? Yes _____ No_____ If yes, please provide details:
7. Have you ever received disciplinary action against you for a school-related incident? Yes _____ No_____ If yes, please provide details:
Pursuant to RCW
9A.72.085, I certify under penalty or perjury under the laws of the State of
Applicant’s Signature
________________________________________________Date _________________