Middle

213 N. BroadwayPO Box 639

Abilene, Ks. 67410

First

Application for EmploymentAbilene usn 435

PLEASE PRINTPosition(s) Applied For: Please check all that apply Date ofApplication / /_ Secretarial _Instructional Assistant _ Classroom Aide _ Paraprofessional _ Food Service _CustodiallMaintenance_ Bus Driver OtherName _

LastAddress _

Telephone Social Security Number '-- _E-mail addressIf you are under 18, can you furnish a work permit? .

Have you ever been employed here before? ..

Are you legally eligible for employment in this country? .

(Proof of U. S. citizenship or immigration status will be required upon employment.)

Date available for work

Type of employment desired 0 Full time o Part-Time o Temporary 0 Seasonal 0 Educational Co-Op

Are you able to meet the attendance requirements of the position?

Have you ever been convicted of a crime other than a minor traffic offense? .(Such convictions may be relevant if job related, but does not bar from employment.)

If yes, please explain: _

Driver's license number (if required by job) _

There will be a drug screening and background check prior to otTer of employment.

State _

EMPLOYMENT HISTORYList your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military service .

.r

From To Employer TelephoneJob Title Address

Immediate Supervisor and Title Summarize the nature of work performed and iob resoonsibilities

Reason for leavin2 Hourly Rate/SalaryFrom To Employer TelephoneJob Title Address

Immediate Supervisor and Title Summarize the nature of work performed and job resoonsibilities

Reason for leaving Hourly Rate/Salary IStart $ per Final $ per

From To Employer TelephoneJob Title Address

Immediate Supervisor and Title Summarize the nature of work performed and job responsibilities

Reason for leaving Hourly Rate/SalaryStart $ per Final $ per

From To Employer TelephoneJob Title Address

Immediate Supervisor and Title Summarize the nature of work performed and job responsibilities

Reason for leaving Hourly Rate/SalaryStart $ per Final $ per

SKILLS AND QUALIFICATIONSSummarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our company.

EDUCATIONAL BACKGROUND

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High School

College Major IDegreeOther

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Area Code( )

Area CodeI( )

Area CodeAPPLICANT JOB APPLICATI(

I certify that all the InformatIOn provided by me In thIs applIcatIOn IS true and complete. I understand that any misstatement,falsification, or omission of information is grounds for refusaJ to hire, or if I am hired and the same is discovered thereafter,termination.

I authorize any of the persons or organizations referenced in this application to give you any and all information concerning myprevious employment, education, or any other information, personaJ or otherwise, with regard to any of the subjects covered by thisapplication, and I release all such parties from aJlliability for any damages that may result from furnishing such information to you.authorize any background checks by any third party.

I authorize you to request, receive, and verify aJl information given on this application and I release you from all damages that mayresult from your doing so.

I authorize you to conduct a criminaJ background investigation using any and aJl methods necessary to successfully complete suchinvestigation and I release you from aJlliability for any damages that may result from your doing so.

The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on thisapplication is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local,state, or federal law.

This application is current for only 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to beconsidered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, withor without cause and without prior notice. I understand that no representative of the Employer has the authority to make anyassurances to the contrary.

I understand that if I am offered provisional employment in the school district that my fingerprints may be taken and a request made fora state and national criminal background check. I further understand that if the results of this criminal history check reveal that I havebeen convicted of any offense or any attempt to commit any offense specified in K.SA. 1999 Supp. 72-1397 and amendments theretothat my employment may be terminated.Signature of Applicant Date --'- -'- _

I am also interested in emplovment with an Educational Coop or Deadstart program. Yes__ No__