School High

SILVER CREEK CENTRAL

SCHOOL APPLICATION FOR

P.O. BOX 270 EMPLOYMENT

Silver Creek, NY 14136

716-***-**** Instructional staff/Substitutes

716-***-**** Location preference:

Elem Middle High School

Reasonable Accommodation: The Silver Creek Central School District complies with the Americans with Disabilities Act and will consider all requests for reasonable accommodations on a case-by-case basis. If you require a reasonable accommodation at any stage of the application or interview process, please contact the Business Office at 716-***-****. Submission of a Resume Does Not Relieve You of the Responsibility for completing All Sections of the Official Application

PERSONAL INFORMATION

Name Last First Middle

Present Mailing Address Telephone No. Permanent Mailing Address Telephone No. Cell No. Years at above address

Have you ever worked for the Silver Creek Central School District under another name? Is additional information relative to change of name, use of an assumed name or nickname necessary to enable a check on your work record? If yes, explain Are you a member of the NYS Teachers’ Retirement System? Yes No If yes, please give your NYS Teachers’ Retirement System Number If not a current member, do you wish to join ? (full-time positions membership is mandatory) Yes No

(Substitute positions only)

Are you a retired teacher? Yes No

If yes, what school district did you retire from?

Personal information Checklist

Willing to Work (check all that Apply) Full Day Half Day Days available to work: Mon. Tues. Wed. Thurs. Fri. Are you over 18 years of age? Yes No

Are you legally authorized to work in the United States? Yes No Criminal Background : “A conviction will not necessarily disqualify you from employment. Factors such as age and date of conviction, the seriousness and nature of the crime, rehabilitation, and the relationship of the crime to the job duties will be considered.” Have you ever been convicted of any offense, whether a felony, misdemeanor or violation, other than a minor traffic violation (DUI, DUAI, or DWI convictions are not minor and must be reported? (do not include sealed convictions or convictions classified as youthful offender) Yes No

Have you ever pled guilty to any offense, whether a felony, misdemeanor or violation, other than a minor traffic violation (DUI, DUAI or DWI convictions are not minor and must be reported)? (do not include sealed convictions or convictions classified as youthful offender) Yes No Have you ever pled nolo contende or no contest to any offense, whether a felony, misdemeanor or violation, other than a minor traffic violation (DUI, DUAI or DWI convictions are not minor and must be reported)? (do not include sealed convictions or convictions classified as youthful offender) Yes No

Do you currently have any pending arrests or criminal investigations against you at this time? Yes No If yes to any of the above, please state the nature and dates of conviction (s) or plea (s) and, if applicable, date (s) of release from prison. Have you received fingerprinting clearance pursuant to a fingerprint and criminal background check from the New York State DCJS and FBI as set forth in the Education Law? Yes No

“Are you able to meet the requirements of the job for which you are applying with or without a reasonable accommodation?” Yes No List extra-curricular activities for which you are qualified and would like to supervise. List persons working for us who know you.

EDUCATIONAL PREPARATION

Name & Location of School:

Major

Sem. Hrs.

Minor

Sem. Hrs.

Diploma or

Degree

High School

College

Graduate School

Special Training

Circle scholastic average of: All Undergraduate College Work A A- B+ B B- C+ C C- Major Field-Undergraduate A A- B+ B B- C+ C C-

Graduate Work A A- B+ B B- C+ C C-

Scholastic Honors STUDENT TEACHING EXPERIENCE

School/ and Critic Teacher Number of weeks. Specific Nature of Position ACTIVITIES

High School College

Other Awards, Honors, Recognition EMPLOYMENT EXPERIENCE

List ALL prior employers starting with the most recent. Use an additional sheet if needed. Name & Address of Employer

Supervisor’s name & Title

From To

Mo. Yr. Mo. Yr.

Reason for Leaving

Annual Salary

Phone Describe in detail the work you did

Name & Address of Employer

Supervisor’s name & Title

From To

Mo. Yr. Mo. Yr.

Reason for Leaving

Annual Salary

Phone Describe in detail the work you did

Name & Address of Employer

Supervisor’s name & Title

From To

Mo. Yr. Mo. Yr.

Reason for Leaving

Annual Salary

Phone Describe in detail the work you did

Name & Address of Employer

Supervisor’s name & Title

From To

Mo. Yr. Mo. Yr.

Reason for Leaving

Annual Salary

Phone Describe in detail the work you did CERTIFICATION/TENURE INFORMATION

Do you have your New York State Certification? Yes No Certification Area: Effective Date

(Please include copy of certification)

Have you previously received tenure in another school district or BOCES? If yes: What school district? In what tenure area? When was previous tenure granted? Have you ever had an application for a teaching, professional or vocational credential (i.e. license, certificate or registration) in New York or any other jurisdiction denied? Yes No

Have you ever surrendered a teaching, professional or vocational credential ( i.e. license, certificate or registration) or had such credential revoked, suspended, invalidated or otherwise subjected to a disciplinary penalty in any jurisdiction? Yes No Have you ever had any sanctions placed on your teaching certificate for any reason? Yes No Have you ever been denied permanent status as a Civil Service employee anywhere? Yes No Have you ever been denied tenure from a school district ? Yes No Have you ever been the subject of an investigation by a school district or any other employer? Yes No Have you ever been dismissed from, resigned from, entered into a settlement agreement or otherwise left employment to avoid investigation and/or dismissal for alleged misconduct? Yes No

Have you ever resigned to avoid denial or tenure or denial of permanent status as a Civil Service employee ? Yes No Have you ever been asked to leave a place of employment (or volunteer position) or resigned in lieu of being terminated? Yes No Have you ever been discharged or separated from a position with a school district or been asked to resign a licensed arrangement? Yes No Is disciplinary action currently pending anywhere against you related to your teaching license teaching certification, Civil Service employment or past or current employment? Yes No

If you answered “yes” to any of the questions, please attach a full explanation for your answer on a separate sheet of paper. UNITED STATES ARMED SERVICES RECORD

Dates: Total Do you have any continuing

From To Branch Rank Months Reserve Obligation? Indicate any employers listed above you do not wish us to contact. Have you ever received tenure in any school district or BOCES in New York State? YES NO If yes, date Have you ever been dismissed or asked to resign an employment position? If yes, explain on a separate sheet.

REFERENCES

Give the names of three (3) references who have closely observed your work as a teacher, employee or student. Recommendations by present and former superintendents, principals and other supervisors preferred. PLEASE PRINT

1 2 3

Name

Position

Address

(include zip code)

Telephone I WAIVE MY RIGHT OF ACCESS TO ANY INFORMATION SUBMITTED BY THESE REFERENCES. Signature of Applicant PERSONAL STATEMENT

Below please describe what you believe to be an ideal learning situation and what your role would be in that situation. I certify that the above information is true and correct to the best of my belief and knowledge. I affirm that I have read the completed application and have not withheld any information or response to any questions. I understand that discovery of any misrepresentation or omission by me in this regard may lead to the denial or employment, or if I am hired, the termination thereof at any time that the misrepresentation or omission is noticed by the District. I hereby grant permission to the Silver Creek Central School District, to contact and investigate my former and current employers, and all other pertinent parties, including but not limited to educational institutions where I enrolled, to fully investigate my background. I authorize the District to verify the information which I have stated in this application or during the interview process to the full extent permitted by law. Pursuant to New York State Law, I agree to sign any additional forms of consent and/or to undergo any additional procedures required by the District, NYSED, NYS DCJS or the FBI to effectuate a criminal record background check. I hereby indemnify, release and forever discharge and hold the Silver Creek Central School District and its officers, agents, and employees, as well as all third parties supplying such information, harmless from any and all claims, demands, judgment and legal fees arising out of or in connection with this investigation, the results, or any lawful use of the results or disclosure thereto. I understand that completion of this employment application does not guarantee that I will be employed by the District. In the event that I am employed, I agree to conform to the District’s rules and regulations. I understand that this application will remain active for One (1) year. If you wish to be considered for employment beyond this time period, I should inquire whether applications are being accepted at that time, and if so, complete a new application. Applicant’s Signature Date An Equal Opportunity Employer – “The Silver Creek Central School District is an equal opportunity employer and does not discriminate on the basis of age, race, creed, color, religion, national origin, sex, sexual orientation, disability, marital status, familial status, arrest or conviction record, genetic predisposition or carrier status, status as a disabled or Vietnam Veteran or victim of domestic violence or any other basis protected by law ( unless a bona fide occupational qualification applies). “

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