Unified School District of de Pere Application For Employment

Unified School District of De Pere
Application For Employment
1700 Chicago Street * De Pere, WI 54115

Phone: (920) 337-1032
Position Applying f o r : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date Available: ___/___/_ _

Available:
_ _ Part Time*
Full Time
*If Part Time, specify hours & days available
Personal Data
1.
Name=-----------..,,..--------...,.,,.....------ Social Security#:---~___]_ _ __

~
2. PresentAddress=----------------------------------=----av
State
Work Telephone: (_ _) _ _-_ __
3.
Home Telephone: (_ _) _ _-_ _ __
4.
Have you worked for the Unified School District of De Pere before? ___ If yes, when and in what capacity?_ _ _ _ __
5.
Can you perform, with or without accommodation, the duties of the position you seek?
with accommodation
If accommodation is needed, briefly describe what is needed:
6.
7.
without accommodation
Have you ever been found guilty of or do you presently have pending any violations of law (felonies and/or misdemeanors) other than minor traffic
violations? (in accordance with State law pending charges or convictions will not be considered unless substantially related to circumstances of
the particular job)
No
Yes
If yes, please attach a complete written explanation.
Have you ever been dismissed or asked to resign from any employment or other position?
Yes No
If yes, please explain and attach further explanation as is n e c e s s a r y - - - - - - - - - - - - - - - - - - - - -
8. Education And Training

Name & Location of High School
Circle the highest grade or year completed in school:
10
11
12
13
14+
Training Beyond High School (College or University, Nursing, Business, Tech/Voe. Etc.)
Name of Institution
and Address
Dates
Attended
From
To
Credits
Earned
Major Field
Degree Conferred & YEAR
....
9. Describe any education or training you have had which is not covered above, such as on the job, correspondence courses, service schools, inservice training, which you feel is relevant to the job for which you are applying. Also include relevant licenses or certificates. (Be Specific)
10. EMPLOYMENT
Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.
Name Of Employer
Telephone
Address
Employed (State Month & Year)

From
To
Name of Supervisor
Weekly Pay
Start
State Job Title & Describe Your Work
Last
Reason for Leaving
Name Of Employer
Telephone
Address

From
To
Name of Supervisor
Weekly Pay
Start
Last
Reason for Leaving
Name Of Employer
Telephone
Address

From
To
Name of Supervisor
Weekly Pay
Start
Last
Reason for Leaving
Name Of Employer
Telephone
Address

From
To
Name of Supervisor
Weekly Pay
Start
Last
Reason for Leaving
Name Of Employer
Telephone
Address

From
To
Name of Supervisor
Weekly Pay
Start
Last
Reason for Leaving
Additional employment data may be attached on a separate sheet. Please include all pertinent information.
DO NOT CONTACT EMPLOYER NUMBER(S)
11. We may contact the employers listed unless you

indicate those you do not want us to contact.
Reason_~-----------------~----------------
12. Freedom from non-prescribed controlled substances is a condition of employment in the De Pere School District. Periodic tests may
be utilized to verify this status.
Are you free from non-prescribed controlled substances? Yes
No
13. Explain any additional experiences, talents or skills that you possess which would be applicable to the position for which
you are applying.
VERIFICATION/AUTHORIZATION
I authorize the Unified School District of De Pere (USDDP), in De Pere, Wisconsin, to make any inquiry of or receive any information from
any person or organization regarding my suitability for employment, and do hereby expressly give permission to these persons or
organizations to provide such information. Such inquires may include, but are not limited to, the verification of any information set forth
in this application, the quality and quantity of my work, my work history and medical records, and my character, qualifications, and
background. In consideration for the cooperation extended to USDDP by release of such information, I forever waive, release, and
covenant not to sue any person or organization, including USDDP and its agents and employees, for providing, obtaining, verifying, or
otherwise acting upon such information. I give this waiver, release, and covenant not to sue for myself, my heirs, assigns and successors
in interest forever. I do so understanding that the information obtained may be such as to disqualify me for employment, or result in
rejection of my application or my dismissal from employment. I understand that such information is sought with confidentiality, and I will
not request copies thereof. I certify that all information provided herein is accurate to the best of my knowledge, information and belief,
and I acknowledge that any false statements, incomplete statements, or misrepresentations may subject me to disqualification, rejection,
or dismissal at any time. A copy of this authorization shall be as effective as the original for the purposes stated above. I HAVE READ AND
UNDERSTAND THE FOREGOING CERTIFICATION, AND SIGN BELOW VOLUNTARILY AND WITH KNOWLEDGE OF ITS CO'ITENTS.
Signature
Date
(Note: This application is subject to consideration by the Unified School District of De Pere for a period of ninety (90) days.)
The Unified School District of De Pere is an equal opportunity employer and adheres to
all applicable Federal and State laws prohibiting discrimination in employment.

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Unified School District of De Pere

Application For Employment

1700 Chicago Street * De Pere, WI 54115

Position Applying f o r : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date Available: ___/___/_ _

Name=-----------..,,..--------...,.,,.....------ Social Security#:---~___]_ _ __

Home Telephone: (_ _) _ _-_ _ __

8. Education And Training

Circle the highest grade or year completed in school:

Degree Conferred & YEAR

Employed (State Month & Year)

State Job Title & Describe Your Work

Reason for Leaving

Employed (State Month & Year)

State Job Title & Describe Your Work

Reason for Leaving

Employed (State Month & Year)

State Job Title & Describe Your Work

Reason for Leaving

Employed (State Month & Year)

State Job Title & Describe Your Work

Reason for Leaving

Employed (State Month & Year)

State Job Title & Describe Your Work

Reason for Leaving

DO NOT CONTACT EMPLOYER NUMBER(S)

11. We may contact the employers listed unless you

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Position Applying f o r : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date Available: _/_/_ _