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APPLICATION FOR NON-CERTIFIED STAFF 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 www.gsd.k12.ms.us (COMPLETED FORM MUST BE RETURNED TO THE PERSONNEL DEPARTMENT) (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) OR 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) 1) 2) 3) 4) READ CAREFULLY AND SIGN THE FOLLOWING STATEMENT: 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 THANK YOU FOR YOUR INTEREST IN GRENADA SCHOOL DISTRICT Revised 7/1/2007 Personnel Department Page 3 ________________________________________ Date Grenada School District PERMISSION FOR BACKGROUND CHECK 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 _____________________________________ Date 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 address: 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 REFERENCE EVALUATION FORM FOR NON-CERTIFICATED POSITION (Applicant to complete Part I only) (Return this form with application, Grenada School District will mail to your references) Part I FOUR REFERENCES ARE REQUIRED 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 employment. 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 Fluent/Precise 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 Annoying Cooperation Outstanding Cooperative Usually Uncooperative Cooperative 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