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EDUTEMPS APPLICATION FOR EMPLOYMENT by HC120218105559

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									                                    APPLICATION FOR EMPLOYMENT
Edutemps Staffing Solutions, LLC. is an equal opportunity employer and does not discriminate on the basis of race,
religion, color, national origin, age, sex, gender, disability or any other characteristic protected by law.


INTRODUCTORY INFORMATION:
Name: ____________________________________________________          Date: _______________________
Address: _______________________________________________________________________________________
City:    _____________________ State:      _______ Zip: __________     Phone:    _________________
Email Address: ____________________________________________________

APPLICANT QUESTIONS:
Type of worked desired:       _______________       Salary desired:    ___________           Date Available:    _________
If hired, can you provide documents required to establish your eligibility to work in the U.S.?          __ Yes __ No
Are you 16 years of age or older?                                                                        __ Yes __ No
How were you referred to [Organization Name]? _______________________________________________________
Have you ever been convicted of, or pled guilty or no contest to, a crime other than a minor traffic
violation?                                                                                               __ Yes __ No
If yes, please explain in detail on a separate piece of paper and include the date of final disposition of the case and the
nature of the offense. This information will not necessarily disqualify you from employment but false or misleading
information will. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation
will be taken into account.

EDUCATION:
High School or last grade completed:
Name & Address of School: _________________________________________________________________________
Course of Study:                 _________________________             Number of years completed:        ______________
Degree/Diploma:                  ______________________________________________________________________
College or Technical School
Name & Address of School: _________________________________________________________________________
Course of Study:                 _________________________             Number of years completed:        ______________

Degree/Diploma:                  ______________________________________________________________________
Other Schooling or Training
Name & Address of School: _________________________________________________________________________
Course of Study:                 _________________________             Number of years completed:        ______________
Degree/Diploma:                  ______________________________________________________________________
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MILITARY EXPERIENCE:
Branch of Service:                      _________________________________                                             From: __________                            To:          ___________
Rank/Type of Service: ____________________________________________________________________________

Job-Related Training/Experience: ____________________________________________________________________



RECORD OF EMPLOYMENT:
List positions starting with most recent:
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Employer: _____________________________________________                                                               Telephone:              _____________________________
Address:            ________________________________________________________________________________________
Position Title: __________________________________ Supervisor: ________________________________________
Start Date: _________                      Date Left: __________                              Beginning Salary: __________ Ending Salary: __________
Duties:             ________________________________________________________________________________________
Reason for Leaving:                     ______________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Employer: _____________________________________________                                                               Telephone:              _____________________________
Address:            ________________________________________________________________________________________
Position Title: __________________________________ Supervisor: ________________________________________
Start Date: _________                      Date Left: __________                              Beginning Salary: __________ Ending Salary: __________
Duties:             ________________________________________________________________________________________
Reason for Leaving:                     ______________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Employer: _____________________________________________                                                               Telephone:              _____________________________
Address:            ________________________________________________________________________________________
Position Title: __________________________________ Supervisor: ________________________________________
Start Date: _________                      Date Left: ___________                             Beginning Salary: _________                               Ending Salary:                _________
Duties:             ________________________________________________________________________________________
Reason for Leaving:                     ______________________________________________________________________________
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



WORK-RELATED REFERENCES: (Do not include relatives)

      Name                                            Occupation                           Years Known                   Contact Information
1.    ____________________                            _________________                    _____________                 ___________________________________________
2.    ____________________                            _________________                    _____________                 ___________________________________________
3. __________________                                 _______________                      ____________                  _______________________________________



                                                                                                                                                                                                        2
STATEMENT (Please read this statement carefully before signing this application):
I understand that employment with EDUTEMPS Staffing Solutions, LLC is at-will, meaning that I or EDUTEMPS may
terminate my employment at any time, or for any reason consistent with applicable state or federal law.
I authorize EDUTEMPS Staffing Solutions, LLC to conduct a thorough background investigation of my work and
personal history, references and verify all data given on this application and during interviews. I hereby release
EDUTEMPS Staffing Solutions, LLC, and its representatives or agents, from any liability that might result from such an
investigation. I authorize all individuals, schools, and firms named to provide any requested information and release them
from all liability for providing the requested information.
I understand that EDUTEMPS Staffing Solutions, LLC requires at my expense, the successful completion of a drug
and/or alcohol test as a condition of employment.
I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for
employment, I must submit a new application. I certify that all the statements in this completed application are
true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to
hire.

I hereby certify that the information present in this application is true, accurate, and complete. Any falsification of this
record will be sufficient cause for disqualification and constitute a release to the employer for liability.

I understand that this application becomes the property of EDUTEMPS Staffing Solutions, LLC and its contracted schools
human resource departments.

I have read the above statement and understand it.



Signature of Applicant: ___________________________________ Date Signed: ________________________



I further understand that employment with EDUTEMPS Staffing Solutions, LLC is contingent upon a satisfactory
clearance of an investigation of a record for felon or misdemeanor conviction in compliance with TEC 22.083. By
completing this application for employment with EDUTEMPS Staffing Solutions, LLC I hereby give EDUTEMPS
permission to make inquiries to the law enforcement agencies for information. I further agree that the information
requested will become a part of my personnel file if I am employed by EDUTEMPS to work in a school; and I also agree
that the information will not be disclosed to me but will be treated as confidential by EDUTEMPS, and I waive any right
to see this information.

______________________________                                                       ________________________________
Social Security Number                                                               Please Print Name

______________________________                                                       ________________________________
Driver’s License Number                                                              Applicant Signature

_______________         ____________                                                 ________________________________
 Race                    Sex                                                         Date of Birth




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For Substitute Teacher Applicants only:

It is our goal to place you in a suitable placement for substitute teaching. Please check the following area in which you are
willing to substitute:

_____ Elementary (Pre-K – 5th grade)
_____ Secondary (6th –8th) _____ (9th -12th)
_____ Special Education
_____ Vocational Education
_____ Alternative School & Program (ex. ISS, for at-risk students)

It is our goal to place you in areas of content that you possess a desire to teach. Please check the following areas of
content you are interested: (this area is for persons only interested in teaching in the secondary 6th-12th grade)

_____ Math
_____ History
_____ Science
_____ English
_____ Technology/Computer Math
_____ Electives(PE, Choir, Journalism, Choir, Theatre, Cosmetology, Barbering, Speech, Home-Economics, Business etc.)
_____ Hall Monitor/Tutor

For administrative professionals only:
Typing Speed: _____________                Yrs. in Clerical/Office Management: __________
Please list all technology skills:

________________________________________________________________
________________________________________________________________


I understand and hereby certify that EDUTEMPS Substitute and Administrative professionals are expected to work at any
or all of our contracted schools locations.

________________________________             ____________________________
Signature                                    Date




Applicant Check List for EDUTEMPS personnel use only:

____ Copy of SS card          ____ Copy of DL      ____ I-9 Form ________W-4 _____TB test
____ Background Cleared       ____ Screening/      ____Transcripts _______STEDI registered
_____Questionnaire            ______ Substitute Training Completed Preferred 1st Work Assignment: _________
_____ Confidentiality Agreement _________ Benefits Waiver ______ References checked Date: _________

____________ Interview Date           Interviewed By:_______________________ Approved Staff Initials: ______



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                                           APPLICANT DATA RECORD

As employers, we comply with governmental laws and regulations regarding employment practices. To help us comply
with government record keeping and reporting requirements, please fill out this Applicant Data Record.

EDUTEMPS Applicants are considered for all positions, and employees are treated during employment with regard to
race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap.

This data is not part of your application for employment. This data is kept separately from applications for employment
and is not considered for employment purposes.

Date: __________

Position(s) Applied for: __________________________________________________________________

Referral Source: _____Advertisement ____ Friend/Relative        ________ Website ________Walk-in ______Other

(Optional)
Check One: _____ Male ______ Female
Check One: _____Black ______Hispanic ______White
           _____American Indian/Alaskan Native ______ Asian/Pacific Islander




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                            Criminal History Record Information Request
                                     (Confidential Information)
EDUTEMPS Staffing Solutions, LLC as a school contractor is required by Texas Education Code Chapter 22 to review
the criminal history of applicants. The information requested below is necessary to obtain the criminal history record
information.

Please Print

Name :_________________________________________________________________________________
        Last                     First                     Middle

Social Security Number: ________________________

Driver’s License Number & State: ___________________________

Mailing Address: _____________________________________________________________________________
                Street                                 City                State/Zip


Please Circle: (optional)

Sex: Male        Female

Ethnicity: African-American      Asian         Hispanic       White       American Indian    Other


I understand that the information I am providing about age, sex, ethnicity will not be used to determine eligibility
employment but will be used solely for the purpose of obtaining criminal history record information.

_______________________________
Signature

__________________________
Date

*This form will be removed from application and filed separately in EDUTEMPS Human Resource Department.




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                                               Benefits Waiver for

                       EDUTEMPS Substitute Teachers & Administrative Professionals


Agreement and Waiver
In consideration of my assignment to LA MARQUE INDEPENDENT SCHOOL DISTRICT by EDUTEMPS
STAFFING SOLUTIONS, I agree that I am solely an employee of EDUTEMPS STAFFING SOLUTIONS for benefits
plan purposes and that I am eligible only for such benefits as EDUTEMPS STAFFING SOLUTIONS may offer to me
as its employee. I further understand and agree that I am not eligible for or entitled to participate in or make any
claim upon any benefit plan, policy, or practice offered by LA MARQUE INDEPENDENT SCHOOL DISTRICT, its
parents, affiliates, subsidiaries, or successors to any of their direct employees, regardless of the length of my
assignment to LA MARQUE INDEPENDENT SCHOOL DISTRICT by EDUTEMPS STAFFING SOLUTIONS and
regardless of whether I am held to be a common-law employee of LA MARQUE INDEPENDENT SCHOOL
DISTRICT for any purpose; and therefore, with full knowledge and understanding, I hereby expressly waive any
claim or right that I may have, now or in the future, to such benefits and agree not to make any claim for such
benefits.



       EMPLOYEE                                             WITNESS


       Signature                                            Signature


       Printed Name                                         Printed Name


       Date                                                 Date




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                               Confidentiality Agreement for Assigned Employees

          between EDUTEMPS Staffing Solutions, LLC and La Marque Independent School District


Assigned Employee Confidentiality Agreement
As a condition of my assignment by EDUTEMPS STAFFING SOLUTIONS to LA MARQUE INDEPENDENT
SCHOOL DISTRICT, I hereby agree as follows:

I will not use, disclose, or in any way reveal or disseminate to unauthorized parties any information I gain through
contact with materials, confidential student records or documents that are made available through my assignment at
LA MARQUE INDEPENDENT SCHOOL DISTRICT or which I learn about during such assignment.

I will not disclose or in any way reveal or disseminate any information pertaining to LA MARQUE INDEPENDENT
SCHOOL DISTRICT or its operating methods and procedures that come to my attention as a result of this
assignment.

Under no circumstances will I remove physical or electronic documents or copies of documents from the premises of
LA MARQUE INDEPENDENT SCHOOL DISTRICT.

I understand that I will be responsible for any direct or consequential damages resulting from any violation of this
Agreement.

The obligations of this Agreement will survive my employment by EDUTEMPS STAFFING SOLUTIONS.



       EMPLOYEE                                               WITNESS


       Signature                                              Signature


       Printed Name                                           Printed Name


       Date                                                   Date




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