Klickitat School District #402

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					                                                      Klickitat School District #402
                                                                P.O Box 37
                                                      Klickitat, Washington 98628
                                                              509-369-4145
                         APPLICATION FOR
                    EXTRA-CURRICULAR POSITION
_____________________
              (Date)

PERSONAL INFORMATION

Name____________________________________________________________________________
                 (Last)                                 (First)                                             (Middle)

Address__________________________________________________________________________
                     (Number & Street)                               (City)                    (State)                             (Zip)

Birth Date__________________________ Social Security No. __________________________

Home Telephone____________________ Message Phone ______________________________


List any physical defects or disabilities which would hinder your performance on the job. Explain:



EDUCATION & TRAINING

Name of School                                           Location                           Dates Attended                     Certificated Earned




CHARACTER REFERENCE

List below three persons other than relatives and former employers who have known you during the past
three years.
_

Name                                                     Address                                                   Telephone No.




Klickitat School District #402 complies with all federal and state rules and regulations and does not discriminate on the basis of race, color, creed, national origin, sex,
marital status, sexual orientation, age, the presence of a disability, or any other basis prohibited by law. The district complies with the Immigration Reform and Control
Act, the Americans with Disabilities Act (ADA), Title IX, and Section 504 of the Rehabilitation Act, and all other state and federal equal opportunity laws.
Employment applications from all groups are encouraged. Inquiries regarding compliance and/or grievance procedures may be directed to Jerry T. Lynch,
Superintendent, Title IX/RCW 28A.640, Affirmative Action Officer, Section 504 Coordinator and ADA Coordinator at P.O. Box 37, Klickitat, WA 98628;telephone
509-369-4195
        Klickitat School District is a drug, alcohol and tobacco-free workplace. Klickitat School District is an Equal Opportunity Employer.
EMPLOYMENT HISTORY

Employer________________________________________ Address__________________________________

Supervisor’s Name_______________________________________Telephone__________________________

Dates of Employment: From__________________________ To _______________________

Specific Duties_____________________________________________________________________________



Reason for Leaving__________________________________________________________________________




Employer________________________________________ Address__________________________________

Supervisor’s Name_______________________________________Telephone__________________________

Dates of Employment: From__________________________ To _______________________

Specific Duties_____________________________________________________________________________



Reason for Leaving__________________________________________________________________________




Employer________________________________________ Address__________________________________

Supervisor’s Name_______________________________________Telephone__________________________

Dates of Employment: From__________________________ To _______________________

Specific Duties_____________________________________________________________________________



Reason for Leaving__________________________________________________________________________



GENERAL INFORMATION

Do you hold a current first aid card?_____ If not, have your ever had first aid training?______
If not, would you be willing to obtain a card before starting employment?______
TRAINING WITH CHILDREN

Approx. Date           Name and Location of Group             Your Position                No. of Children in Group




EMPLOYMENT PROCEDURES

   1. The applicant must provide a completed application form.
   2. All interviews will be initiated and scheduled through the office.
   3. A personal interview is required before an applicant can be recommended for employment.
   4. A W-4 form must be completed within 24 hours after notification of employment.
   5. The applicant must fill out a Washington State Patrol Criminal History Information Request and be
      fingerprinted by the County to be sent to the F.B.I. within 24 hours after notification of references.
   6. The applicant understands that the Klickitat School District may contact former employers and
      references.

AUTHORIZATION

I hereby certify that all the information I have provided in this application is true and correct to the best of my
knowledge. I authorize the Klickitat School District to conduct reference checks to obtain information relating
to my application for employment. I am advised that the reference checks may include information on my
character, general reputation, and personal characteristics as they may be related to my ability to perform the
job for which I am applying.


Signature of Applicant______________________________________ Date________________________

     Position Applying For_______________________________________________________

				
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