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Professional Reference Form - Excel

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					                                     Georgia Bureau Of Investigation
                                    Georgia Crime Information Center

                                                  Consent Form

I hereby authorize the Coweta County School System to receive any Georgia criminal history record
information pertaining to me which may be in the files of any state or local criminal justice agency in
Georgia.

Have you ever been convicted by federal, state or other law enforcement authorities or pleaded nolo
contendere for violations of any federal law, state law, county or municipal law, regulations or
ordinance? ________ Yes ________ No



Last Name                                 First                                            Middle


Current Address                           City                            State                Zip

                                                                                                    
Race              Sex                     Date of Birth                             Social Security Number



Signature                                                                 Date


Notary Public                                                             Expiration Date



Special employment provisions (check if applicable):

            Employment with mentally disabled (Purpose code "M")
            Employment with elder care (Purpose code "N")
 X          Employment with children (Purpose code "W")

One of the following must be checked:
            This authorization is valid for 90/180/______ (circle one) days from date of signature.
            I, ___________________________________________ give consent to the above named to perform
            periodic criminal history background checks for the duration of my employment with this company.


            A copy of your driver's license or picture ID is required to complete this form.
                                                                                                          Revised 1/2008
                                             Coweta County School System
                                                               Reference Form
To:                                                                           Please return this form promptly to:
       Name of Reference
                                                                              Director of Human Resources
       Address                                                                Coweta County Board of Education
                                                                              P.O. Box 280
       City                     State        Zip                              Newnan, Georgia 30264

                                                                              Phone       (770) 254-2803
                                                                              Fax         (770) 254-2757

I have submitted an application for a position as a __________________________________. Please check the appropriate columns
below and mail this form at your earliest convenience to the address given above. I authorize the confidentiality of this information.


               Last Name                                         First Name                                     Middle

         Signature of Applicant                           Social Security Number                                 Date

                                                    CONFIDENTIAL INFORMATION
PERSONAL TRAITS                                    Excellent           Good            Fair              Poor              Not Observed
   Stamina
   Dress-Grooming
   Self Discipline
   Organizational Skills
   Influential Personality
   Tactfulness
   Self-Control
   Common Sense
   Willingness to Give Extra Time/Effort
   Acceptance of Constructive Criticism

PROFESSIONAL SKILLS
   Quality of Work
   Technical Skills for Position(s) Sought
   Written Communication
   Spoken Communication
   Response to Deadlines
   Care & Use of Supplies & Equipment
   Record Keeping
   Cooperation - Team Player
   Loyalty to System/Company
   Attendance
   Punctuality
   Prospects of Success
OVERALL EVALUATION
                                             15 14 13 12          11 10 9 8        7 6 5 4             3 2 1 0
Do you know of any reason this person should not work around children?               If yes, explain reason(s) on back.
Should we telephone you for additional information?                 Telephone Number
Dates of employment/relationship: From                          to                    Relationship to Applicant:
Would you employ this applicant for the above named position?              Yes                No                   Maybe


                           Signature                                                                 Official Position

                 Telephone                                      Date                            School or Company Name
    Coweta County School System
     Application for Classified Personnel
                                                                                                              General Information
                     Department of Human Resources                                                  Name:
                              P.O. Box 280                                                            Last
                         Newnan, Georgia 30264
                     Phone (770) 254-2803 or 254-2804                                                 First
                           FAX (770) 254-2757
                         www.cowetaschools.org                                                        Middle

                             Section I - Position Desired                                           Social Security Number:

    CLERICAL                                 FOOD SERVICE                                                                           
         Secretary                                Cook
         Bookkeeper                               Worker                                            Present Address:
         Clerk                                    Cashier
                                                                                                      Street
    PARAPROFESSIONAL                         TRANSPORTATION
         Regular Classroom                        Bus Driver
         Special Education                        Bus Monitor
         Media                                    Bus Garage                                          City

                                                                                                      State
    NURSE                                         PERMANENT SUBSTITUTE
         RN                                                                                           Zip Code
         LPN                                      ART INSTRUCTOR
                                                                                                      Email
    TECHNOLOGY                               AFTER SCHOOL PROGRAM
         Technician                               Site Coordinator                                  Telephone:
         Technology Specialist                    Worker
                                                                                                      Home
    OPERATIONS                               ADMINISTRATOR
         Custodian                                Business Services                                   Cell
         Maintenance                              Technology
         Grounds                                  Transportation                                      Other
                                                  Food Service
    OTHER                                         Operations                                        Parent's or Permanent Address:

                                                                                                      Street
All applicants must complete this application form. The accuracy and completeness with which
this form is filled out will be factors in the consideration of your application.

This application will be retained in our active files for one (1) year. In order to maintain this     City
application in an active status after one (1) year, your request must be in writing.
                                                                                                      State
Please allow three weeks for processing this application prior to contacting our office.
                                                                                                      Zip Code

                                     OFFICIAL USE ONLY                                                Phone
                  Date Received ______________________
    References                                Release Statement
    Proof of Education                        Application Complete                                  DATE
                                               Section II - Educational Training

A copy of your highest degree in education is required to complete application.


         Dates                                Name of School                                  Degree           Major           Minor
                              (high school, vocational, college, and graduate school)




                                                  Section III - Other Training

Indicate any foreign languages you can speak, read and/or write:


Are you able to communicate with sign language?

What musical instruments do you play?

What training or experience have you had which would qualify you for a food service position?




Describe any specialized training, apprenticeship, skills and extracurricular activities that you feel have significantly contributed to
your preparation for the position you seek.




                                               Section IV - Employment Record

Beginning with current position, list the last ten (10) years of experience.

         Dates                     Position                   Name and address of Employer                     Reason for Leaving




Describe your experiences that you feel have contributed to your preparation for the position you seek.
      A     B   C       D   E   F    G     H       I    J    K   L    M     N     O     P   Q      R    S    T     U      V     W    X      Y   Z
1                                          Section V - Military Experience
2
3 Branch of Service:                                      Induction Date:                                      Separation Date:
4 Highest Rank:                                        Type of Discharge:
5 Provide copy of military discharge form DD 214.
6
 7                                                      Section VI - Specialized Skills
 8
 9   Do you presently hold a valid teaching certificate?                   Field(s):                                   State:
10
11   Validity Period:                                   to
12
13   Do you presently hold a Georgia paraprofessional license? ___________             Validity Period: _____________ to _____________
14
15   Type of driving license now held:                           License No.:                             Expiration Date:
16
17   Years of driving experience:         Car                    Truck                      Bus
18
19   If you are applying for a school bus driver position, are you willing to attend a driver training course?
20
21   Check box if proficient:       Typing             Bookkeeping         Calculator             Copy Equipment                PC
22                                  Other (list)
23
24   Do you consider yourself computer literate?                     Which tools are you proficient in (e.g., Internet, spreadsheet,
25   database, word processing, desktop publishing)?
26
27                                    Section VII - Personal and Professional Information
28
29   Are you presently employed with any school system?                            Name of system:
30
31   Have you ever been dismissed from employment?                   Yes                    No         If yes explain:
32
33
34
35
36
37
38
39
40
41   Do you have relatives employed by the Coweta County School System?                     Yes                  No
42
43   Who:                                                                       Relationship to you:
44
45   Where:
46
47   Have you ever been convicted by federal, state or other law enforcement authorities or pleaded nolo contendere for violation
48   of any federal law, state law, county or municipal law, regulation or ordinance? Do not include anything that occurred
49   before your seventeenth birthday. Do not include minor traffic violations for which a fine of $100 or less was imposed.
50                                                       Yes                  No
51
52                Violation                        Date              Court, State, County Where Charged                       Disposition
53
54
55
56
                                                   Section VIII- References
Reference forms included with your application should be given or mailed to your listed references. All references
must be mailed directly to the Department of Human Resources and will be considered confidential information.

Persons listed as references should be able to answer questions concerning the applicant's qualifications for the position
sought. The most recent or former employer(s), supervisor(s), and other appropriate persons who have direct knowledge
of the applicant's work must be included. Neighbors, friends, or relatives should not be included.

Please list references. Complete addresses are required, including zip codes.



  1.
                    Name                                  Title                      Business Phone                  Home Phone


                     Street                               City                            State                         Zip


  2.
                    Name                                  Title                      Business Phone                  Home Phone


                     Street                               City                            State                         Zip


  3.
                    Name                                  Title                      Business Phone                  Home Phone


                     Street                               City                            State                         Zip


                                             Section IX - Signature Statement

By filing an application for employment with the Coweta County School System, if employed, I agree to abide by all the policies as
set forth by the Coweta County Board of Education. I authorize full investigation of the information given in this application and
consent to the representatives of the Coweta County School System contacting my references, previous employers, schools
attended, court officials and law enforcement authorities. I also understand that any misstatement or omission of any information
requested shall be a reason for non-employment or immediate dismissal from employment.


I understand and agree to a criminal record check pertaining to me which may be in the files of any state or local criminal justice
agency in Georgia.

The application, transcript, references and other data are the property of the Coweta County Board of Education and will not be
returned to the applicant. They will be kept on file for one (1) year.

I consent for any former employer of mine to furnish any information from my personnel file or evaluation relative to my
performance as an employee, and I waive any right I may have for such information to remain confidential.


APPLICANT'S SIGNATURE:                                                   SS#                              DATE:

The Coweta County Board of Education is an equal opportunity employer and does not discriminate in employment on the
basis of race, color, sex, religion, creed, national origin, age, or disability.

Non-Discrimination Compliance Coordinator:                          Associate Superintendent
                                                                     Coweta County Schools
                                                                    Coweta County Schools
                                                                     P.O.
                                                                    P. O. Box 280
                                                                     Newnan, Georgia 30264
                                                                    Newnan, Georgia 30264
                                                                    (770) 254-2802
               To Be Completed by Administrative, Clerical, and Paraprofessional Applicants

This section must be completed in applicant's own handwriting and submitted to the Coweta County School System along
with a copy of your highest degree of education and a copy of your military discharge.



Please describe in narrative form additional information applicable to the position for which you are applying, including but not
limited to, particular skills and experiences, awards, jobs held, military experience, travel, hobbies and special interests.




                                                                     -       -
                      Signature                                Social Security Number                          Date

				
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Description: Professional Reference Form document sample