MAINE SCHOOL ADMINISTRATIVE DISTRICT NO. 64

P.O. Box 279, Corinth, Maine  04427

Telephone (207) 285-3334

Fax (207) 285-4343

 

APPLICATION FOR NON-TEACHING POSITION

 

THE M.S.A.D. NO. 64 DOES NOT DISCRIMINATE IN THE OPERATION OF ITS EDUCATIONAL AND EMPLOYMENT POLICIES AND WILL HONOR ALL APPROPRIATE LAWS RELATIVE TO DISCRIMINATION.

 

Name of applicant __________________________________  Date ____________________

 

Permanent address_________________________________________ Phone  ____________

 

Position applying for (Custodian, Cafeteria Worker,):    ______________________________

Ed. Tech., Secretary, etc.             ______________________________

Position location:   ___________________________________________________________                                                                                 

Are you currently employed? __________  When will you be available?  ________________

 

EDUCATIONAL BACKGROUND

Transcripts, including grades, from all colleges/universities attended must be provided.  It is essential that this sections be completed.

 

High School Attended

Diploma

Year Graduated

Course

 

 

 

 

 

College/Univ. Attended

Degree Awarded (if any, list major)

No. Years

Attended

Grade Point

Average

 

 

 

 

 

 

CERTIFICATION

List certification(s) you hold and provide copies of certificates:

 

Type

State

Date Issued

Date of Expiration

 

 

 

 

 

 

 

 

 

Have you been fingerprinted and undergone the Criminal History Check that is mandatory of all individuals who work in the public schools in this state?              Yes ______    No ______

 

(Note:  If yes, please provide a copy of your authorization card issued by the Department of Education if you have not already done so.)

 

Are you a member of the Maine State Retirement System?  Yes____  No____

 

SPECIAL SKILLS:

 

Do you hold a valid driver’s license?  State ___________    Endorsement ____________       

 

To be completed by clerical applicants:

            Typing: ______Yes ______ WPM         ______ No

            Shorthand:       ______ Yes ______WPM         ______ No

 

What office machines are you familiar with? ______________________________________

__________________________________________________________________________

__________________________________________________________________________

 

What other special skills do you have or licenses do you hold that may be relevant to this position? __________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 

EXPERIENCE: Please list all previous employment starting with the most recent job held.  Use the back of the application if necessary.  Please account for any gaps in employment during the past ten years on the back of the application.

From(month/year)

To(month/

year)

 

Position

 

Duties

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BACKGROUND:                                                                                         

 

Have you ever been disciplined, discharged, or asked to resign from

a prior position?                                                                                                Yes ___ No ___

 

Have you ever resigned from a prior position after a complaint had

been received against you or your conduct was under investigation or

review?                                                                                                            Yes ___ No ___

 

Has your contract in a prior position ever been non-renewed?               Yes ___ No ___

 

Have you ever been charged with or investigated for sexual

abuse or harassment of another person?                                                            Yes ___ No ___

 

Have you ever been convicted of a crime (other than a minor

traffic offense)?                                                                                     Yes ___ No ___

 

Have you entered a plea of guilty or “no contest” (nolo contendere)

to any crime (other than a minor traffic offense)?                                                Yes ___ No ___

 

Have you ever had a professional license or certificate suspended

or revoked in any state, or have you ever voluntarily surrendered,

temporarily or permanently, a professional license or

certificate in any state?                                                                           Yes ___ No ___

 

Has any court ever deferred, filed or dismissed proceedings without

a finding of guilty and required that you pay a fine, penalty or

court costs and/or imposed a requirement as to your behavior or

conduct for a period of time in connection with any crime (other

than a minor traffic offense)?                                                                             Yes ___ No ___

 

If you have answered YES to any of the previous questions, provide full details on an additional sheet including, with respect to court actions, the date and offense in question, and the address of the court involved.  Conviction or other disposition of a crime is not necessarily an automatic bar to employment.

 

How many days have you missed from work during the past two years?_____________

 

REFERENCES: List three, two of whom are most recent supervisors, who can comment on your ability and whom we may contact.  In addition, please provide three letters of reference from persons who are not related to you (may be from references listed below).

 

Name

Position

Address

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

My signature below constitutes authorization to check my employment history, including without limitation, criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any state, local or federal agency.  I further authorize those persons, agencies or entities that the M.S.A.D. No. 64 contacts in connection with my employment application to fully provide the M.S.A.D. No. 64 any information on the matters set forth above.  I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the M.S.A.D. No. 64, its agents or officials, or against any provider of such information.

 

I understand that information submitted in and with this application may be disclosed to a screening and/or interviewing committee, which may include board members, administrators, other staff, and members of the community.  I give my consent to this disclosure.

 

Signature ___________________________________ Date ___________________________

 

 

 

APPLICATION FOR NON-TEACHING POSITION CHECK LIST: The completed employment application cannot be evaluated unless of the following materials have been provided:

 

            ____ Application form fully completed

            ____ Gaps in employment during the past ten years explained

            ____ YES to any of the questions in the Background section explained

            ____Copy of transcripts enclosed

            ____Copy of Criminal History Record Check (CHRC) card enclosed

            ____ Application signed

 

 

NOTE:  All application materials become the property of the M.S.A.D. No. 64.  None will be returned.  Providing any false or misleading information on this application or in the application or employment screening process shall be fully sufficient grounds to refuse to employ the applicant or, if the applicant has been employed, to immediately dismiss the applicant/employee.