OFFICE USE ONLY INDEPENDENT SCHOOL DISTRICT 829 I am applying for: by fBL207G

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									                      INDEPENDENT SCHOOL DISTRICT 829
                          WASECA PUBLIC SCHOOLS
                             501 EAST ELM AVE
                          WASECA, MINNESOTA 56093


                    LICENSED EMPLOYMENT APPLICATION

We appreciate your interest in applying for employment with the Waseca Public Schools. We
believe that every individual should be treated fairly, equitably and without discrimination
because of race, color, creed, religion, national origin, gender, marital status, status with regard
to public assistance, disability, sexual orientation, or age as required by Minnesota and Federal
laws. Inquiries regarding compliance with these laws may be directed to the District Title IX
Director or to the Director of the Office for Civil Rights, Department of Health, Education and
Welfare, Washington, D.C.

Each time you apply for a position, you must send a new letter of application. Applications are
kept on file for a period of twelve months from date of receipt of application. You may use your
resume to supplement this summary. However, please complete the entire application.

Name:_______________________________________________________Date: ____________

Position applied for:_______________________Phone: (w)____________ (h) _____________

Address:________________________________City:____________State:______ZIP: ________

How long at this address?_______________ Date available for employment? _______________

Armed Forces: ___Yes ___No Branch:____________Type of discharge: __________________

Are you legally eligible for employment in the United States?        ___Yes         ___No

If during the past five (5) years you have been convicted of a crime for which a jail or prison
sentence was or could have been imposed, place an "X" in the box and attach a separate sheet
with details.

If you have ever been convicted of any offense involving the sexual molestation, physical or
sexual abuse, or rape of a child, place an "X" in the box and attach a separate sheet with details.




                           AN EQUAL OPPORTUNITY EMPLOYER
                                                                                            8/94
                                                                                    Revised 9/10
                                   EDUCATION
Professional Information
Minnesota Teaching License No.: __________________________________________________

List specific field(s): ____________________________________________________________

Other teaching licenses held: ______________________________________________________


                    SCHOOL            SCHOOL             COURSE OF     # OF YEARS
                     NAME            LOCATION            STUDY OR      COMPLETED
                                                          DEGREE
High School



College



Other




Subjects of special study or research work: ___________________________________________

______________________________________________________________________________




                        PROFESSIONAL REFERENCES
                                 (Excluding Relatives)

 NAME & OCCUPATION                    ADDRESS                        PHONE
1.

2.

3.


                       AN EQUAL OPPORTUNITY EMPLOYER
                                                                                 8/94
                                                                         Revised 9/10
                                     EMPLOYMENT
Please give an accurate and complete full-time and part-time employment record. Start with the
present or most recent employer.
=====================================================================
Company name:___________________________________Telephone:( ) _________________

Address:________________________________________Employed: From______To ________

Name of supervisor_______________________Weekly pay: Start__________End __________

State job title and describe your work: ______________________________________________

______________________________________________________________________________

Reason for leaving: _____________________________________________________________
******************************************************************************
Company name:___________________________________Telephone:( ) _________________

Address:________________________________________Employed: From______To ________

Name of supervisor_______________________Weekly pay: Start__________End __________

State job title and describe your work: ______________________________________________

______________________________________________________________________________

Reason for leaving: _____________________________________________________________
******************************************************************************
Company name:___________________________________Telephone:( ) _________________

Address:________________________________________Employed: From______To ________

Name of supervisor_______________________Weekly pay: Start__________End __________

State job title and describe your work: ______________________________________________

______________________________________________________________________________

Reason for leaving: _____________________________________________________________
******************************************************************************
Explain any additional experiences, talents or skills that you possess which would be applicable
to the position for which you are applying:

______________________________________________________________________________

                         AN EQUAL OPPORTUNITY EMPLOYER
                                                                                         8/94
                                                                                 Revised 9/10
______________________________________________________________________________

I have answered all questions to the best of my knowledge and I, hereby, certify that the facts set
forth in the above employment application are true and complete. I understand that any
misrepresentations or willfull omissions on this application shall disqualify me as an applicant or
be sufficient cause for dismissal if I am hired.


Date_____________        Applicant's Signature ________________________________________


Note: Once an offer of employment has been made, the District may require the successful
applicant to submit to a pre-employment physical or other pre-employment tests, at the
employer's expense.

NOTICE:        Please be advised that under the provision of the Minnesota Government Data
               Privacy Act, some of the data on this application may be classified as private or
               confidential data. This data is being collected as part of the application process
               and will be used by the school district for hiring decisions. You are not legally
               required to provide this data. Failure to fully complete the application form may
               prevent the District from processing your application in a timely manner and from
               fully considering your qualifications for employment.

ALIEN STATUS:         After July 1, 1987, no one can be employed without proof of citizenship.
                      The final candidate for each position will be requested to fill out an INS
                      Form. Copies of the drivers license and social security card (or other
                      proof of citizenship) will be duplicated and kept on file.

VETERAN'S PREFERENCE:                 If you are a veteran or the spouse of a deceased or disabled
                                      veteran and wish to claim veteran's preference, you must
                                      present a legible photocopy of your DD214 to the
                                      Personnel Director. If your claim is approved, five or ten
                                      additional points will be added to your final passing score.

BACKGROUND CHECKS:                    Finalists for positions applied will be subject to paying a
                                      $23.85 fee payable to Waseca Public Schools to cover the
                                      cost of a state criminal history background check as
                                      required under Minnesota State Statute 123B.03, and in
                                      accordance with Minnesota State Statute 299C.62.




                          AN EQUAL OPPORTUNITY EMPLOYER
                                                                                           8/94
                                                                                   Revised 9/10
                               WASECA SCHOOL DISTRICT 829
                               AFFIRMATIVE ACTION SURVEY
Applicants are considered for all positions, and employees are treated without discrimination in
regard to race, color, creed, religion, national origin, gender, disability, age, marital status, sexual
orientation, or status with regard to public assistance.

The information requested below will be used to determine if our recruitment efforts are reaching
all segments of the community and to meet governmental reporting requirements. This
information will not affect you as an applicant; nor will it be placed in your personnel file or be
given to anyone who makes hiring decisions. Although providing this information is voluntary,
we would appreciate your cooperation and assistance in our effort to ensure equal employment
opportunity.

PLEASE PRINT
Name: _______________________________________________________________________
Phone: (   ) ___________________________________________________________________
Address: ______________________________________________________________________
              Street Address                City              State       Zip

Position Applied For:________________________________ Date Applied: _______________
******************************************************************************
Check One: ( ) Male ( )Female
Race/Ethnic Group - Check one of the following:
( ) Caucasian: (Not of Hispanic origin) Includes persons having origins in any of the original
               peoples of Europe, North Africa, or the Middle East.
( ) Black:     (Not of Hispanic origin) Includes persons having origins in any of the Black
               African racial groups.
( ) Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other
               Spanish culture of origin, regardless of race.
( ) American Indian/ Alaskan Native: Persons having origins in any of the original peoples of
               North America, and who maintain identifiable tribal affiliation through
               membership and participation or community recognition.
( ) Asian/Pacific: Persons having origins in any of the original peoples of Islander: the Far East,
               Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area
               includes, for example; China, Japan, Korea, the Philippine Islands, and Samoa.

Check if any of the following are applicable:
( ) Vietnam Era Veteran       ( ) Disabled Veteran ( ) Handicapped Individual

How did you learn about this position?
___Posted job announcement at this office ___Want Ad-Waseca Newspaper
___Friend or relative                     ___Want Ad-Other MN Newspaper
___State Employment Office (Job Service) ___Want Ad-Newspaper other State
                            AN EQUAL OPPORTUNITY EMPLOYER
                                                                                                8/94
                                                                                        Revised 9/10
___Private Employment Agency                  ___Walk-in
___Rehire                                     ___MASA Web Site
___EdPost Web Site                            ___Other(explain)_________________


                             AUTHORIZATION FOR RELEASE
                                  OF INFORMATION


I authorize Waseca Public Schools, Waseca, Minnesota, and any of its duly authorized
representatives, to communicate with and obtain information about me from past employers and
personal references, as well as my criminal history, if any, and military service records.


Any information from my previous employers shall include all written observation, evaluations,
reprimands, and/or notices of deficiency which were included and made part of my personnel file
while I was employed by any particular employer. I waive any and all claims that I may now
have or that might arise in the future as a result of the release of the information referred to
herein by any employer, agency or individual to whom this authorization is delivered.


A photocopy of a signed copy of this authorization may be used the same as one containing an
original signature.




____________________                  ________________________________________________
Date                                                    Applicant's Signature

                                      ________________________________________________
                                                        Social Security Number

                                      ________________________________________________
                                                        Date of Birth

                                      ________________________________________________
                                                        Full Name (first, middle, last)

                                      ________________________________________________
                                                        Driver's License Number



                           AN EQUAL OPPORTUNITY EMPLOYER
                                                                                             8/94
                                                                                     Revised 9/10

								
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