Check Doctor License in Mississippi - DOC

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                                                        GRENADA SCHOOL DISTRICT                                                             Page 1 of 6
                                                                  P.O. BOX 1940
                                                            253 SOUTH MAIN STREET
                                                           GRENADA, MS 38902-1940
                                                Telephone: (662) 226-1606      Fax: (662) 226-7994
                                                    (Please write legibly and if possible in blue ink)
The accuracy and completeness with which this form is prepared will be a factor in its consideration. Applications are sent to all who request them, regardless of
existing vacancies. Applications and personnel records must be screened by the Personnel Department. Candidates are advised to communicate with the
Personnel Department, 253 South Main Street, Grenada, MS 38901 (662-226-1606) about matters of employment in the Grenada School District.

            Position Desired                                          Date of Availability                                Date of Application
Example: (Teacher Assistant, Secretarial, Clerical, Food Service, Bus Driver, Substitute, etc.)

According to the “No Child Left Behind Law of 2002”, if you are applying for an Assistant Teacher
Position you are required to have the following:

      48 Hours of College Credit OR an Associate of Arts Degree from a Junior College or Community College
      (Please include copy of college transcript)


       Must have passed a Mississippi Assistant Teacher Test (Please include copy of transcript)

                                                                           ________ Social Security Number                                    / __ /______
Last Name            First Name      Middle
(Name – MUST BE as it appears on Social Security Card)

Present Address:                                                                                                    _          ________________
                              (Street)                                                       (City)                (State)        (Zip)           (Phone)

Permanent Address:__________________________________________________________
       (Mailing)             (Street)                                         (City)                  (State)         (Zip)           (Phone)

Email Address:__________________________________________Cell Phone: _________________________

Driver License Number _______________________Expiration Date: __________________

Have you ever been previously employed with Grenada School District? _ Yes _ No
If yes, when? __________________________Position? _____________________________

High School, college, and / or technical education: A copy of your high school diploma, GED certificate, vocational certificate,
and/or college transcript must be attached to this application.

Circle the highest grade or year completed through High School
                                                                                                          Name and Location of High School
7 8 9 10 11 12 Year graduated: _____GED _______                                                       __________________________

Do you hold a Mississippi Teacher’s License? _Yes                              _ No (PLEASE ATTACH COPY)
Do you hold any of the following certificates: School Bus Driver’s Certificate                                  _Yes         _ No
School Food Service Supervisor Certificate _Yes _ No School Food Service Manager Certificate _Yes _ No

                                                                            Revised 7/1/2007
                                                                          Personnel Department
                                                                                 Page 1
Have you ever been involuntarily released from employment? _Yes                   _ No
If Yes, where and please explain? ________________________________________________
Have you ever filed a Workers Compensation Claim? _Yes                 _ No
Have you been to a doctor in the past year? _Yes             _ No
Have you ever been arrested for a felony crime? _Yes              _ No
Are you a U.S. Citizen? _Yes         _ No
If No, do you have a VISA to allow you to work in this country? _Yes              _ No
Whom should we contact in case of emergency? ____________________________ _________________
                                                     Name                                     Telephone
Employment History (List current position or last job held first). You may attach additional sheets if necessary.

Company Name                      Address                Phone             Job Title               From Date        -   To Date

Training Beyond High School (college or university, nursing, business college, military, vocational school, etc.)
 Name and Location                                             Dates Attended            Degree and Date Received

Do you have experience in using word processing or any type of spreadsheet software?
_ Yes _ No If yes, please explain: ___________________________________________________


Grenada School District does not discriminate on the basis of race, color, national or ethnic origin, sex, disability, religion,
veteran status, or age in the admission to and provision of educational programs, activities, and services or employment
opportunities and benefits. Dr. David Daigneault, Superintendent, P.O. Box 1940, Grenada, Mississippi 38902-1940, (662)226-
1606, has been designated to handle inquires and complaints regarding the non-discrimination policies of the Grenada School
District. The Grenada School District is an equal employment employer.

                                                             Revised 7/1/2007
                                                           Personnel Department
                                                                  Page 2
References: (Minimum of four REQUIRED).             Include superintendent, principals, or supervisors with whom you
are working, or have worked. Persons who directed your professional preparation (including student teaching
supervisor) should also be listed if you have had no teaching experience.

       Name                                                          Address                             Phone
  (Dr.,Mr.,Mrs.,Miss)                Position                       (Required)                      (include area code)




        It is understood and agreed upon that any material misrepresentation by me in this application may
    result in cancellation of this application and any conditional offer of employment that may have been
    made and/or separation from the Grenada School District’s service if I have been employed.
        I give the Grenada School District the right to contact all references and to secure additional job-
    related information about me.       I hereby release from liability the Grenada School District and its
    representatives for seeking such information, and all other persons, corporations, or organizations for
    furnishing such information.
        This application will remain in the active file for a period of one year. At the conclusion of that
    time, if I have not heard from the Grenada School District and still wish to be considered for
    employment, it will be necessary to fill out a new application.

    ______________________________________________________                       _______________
    Applicant’s Signature                                                                Date


                                                     Revised 7/1/2007
                                                   Personnel Department
                                                          Page 3

                                 Grenada School District

I give my permission for Grenada School District to conduct a background screening

check (Senate Bill 2658) with law enforcement, the child abuse registry, previous employers,

and any other persons to determine my suitability in working with children. I understand that

this permission is a part of my application for a position as a school employee of Grenada

School District.   I further understand that this information will be used with regard to the

attached application,

__________________________________________                     ______/_____/_______

Signature of Applicant                                         Social Security Number

                                          Revised 7/1/2007
                                        Personnel Department
                                               Page 4

To Whom It May Concern:

I have submitted an application for employment with Grenada School District
and have used you/your organization as a reference. This is your authority to
release any information that the school district may request from you regarding my
past employment record and/or character.

I realize that this request does not constitute an offer of employment by the
Grenada School District.

Please return the enclosed form in the pre-stamped envelope to the following

      Dr. David Daigneault, Superintendent
      P.O. Box 1940
      Grenada, MS 38902-1940

      Attention: Personnel Department

                                       Signature of Applicant

                                    Revised 7/1/2007
                                  Personnel Department
                                         Page 5
                                                           Grenada School District
                                                            253 South Main Street
                                                             Grenada, MS 38901
(Applicant to complete Part I only)      (Return this form with application, Grenada School District will mail to your references)

                                                                       Part I

  Applicant Name                                                                                      Social Security No. XXX-XX- _ _ _ _

  Home Telephone                            Work Telephone                                Position Desired

  Please complete the evaluation found in PART II below based on your knowledge of my background and return this form in the pre-stamped
  envelope to the address at the bottom.

  I hereby      _ Waive      _ Do Not Waive         my right to access of this confidential recommendation obtained for my application for

  Applicant Signature__________________________________________               Date______________________________________

                                                                   Part II
             (STOP) - this is to be completed by evaluator of the above applicant)
  Command of English Language           Extremely            Correct in Usage              Usually Correct            Frequently Incorrect
  Attendance Record
                                       Outstanding            Average, Some               Fair, More than              Poor Attendance
                                    Attendance Record,            absences               average number of                 Record
                                     Very few absences                                        absences
  Personal Appearance
                                       Appropriate             Inappropriate                Satisfactory               Poor
  Intelligence                         Below Average            Average                    Above Average

  Professional Attitude                    Always                                              Usually                   Frequently
                                         Professional              Professional              Professional               Unprofessional
  Use of Sound Judgment                  Exceptional                 Good                       Fair                     Unreliable
                                              in                       in                         in                         In
                                          Judgment                Common Sense                Judgment                    Judgment

  Reliability                             Always                    Usually                   Fairly                     Inconsistently
                                         Dependable                Dependable                Reliable                       Reliable
  Character                              Outstanding              Above Average            Average                      Fair

  Relationship with Others               Superior                 Above Average            Satisfactory                  Frequently
  Cooperation                           Outstanding                Cooperative                Usually                   Uncooperative

  1.     Would you recommend applicant for an educational position in the Grenada School District? Yes No
           If no, please explain._____________________________________________________________________________

  2.     Would you reemploy?       Yes           No
           If no, please cxplain._________________________________________________________________________

  3.     General Comments: ____________________________________________________________________________

  Name (print/type): _____________________________________________________Title ______________________________

  Signature                                                                                              Date
  School District/Business Address                                                                  Telephone____________________

                                                                   Revised 7/1/2007
                                                                 Personnel Department
                                                                        Page 6

Description: Check Doctor License in Mississippi document sample