Oneida • Herkimer • Madison

BOCES

(Include Area Code)

City State Zip Code

POSITION PREFERENCE

PERSONAL INFORMATION

Teaching

Substitute Teaching

Subject

Administration

Position

Non-Teaching

Position

Name Present Mailing Address Tel.

Cell

E-mail

Permanent Mailing Address

Social Security No. NYS Retirement System No. Are you capable of performing, in a reasonable manner, the activities involved in the job or occupation for which you have applied? Yes No If No, explain: Do you have a legal right to work in the United States? Yes No If you are an alien with a legal right to work in the United States, and are applying for a teaching position, do you intend to apply for United States Citizenship? Yes No

Did you serve in the U.S. armed forces and, if so, when and in what theater? Yes No

(Dates and Theater)

Did you receive a dishonorable discharge? Yes No N/A

(A dishonorable discharge is not an absolute bar to employment, and other factors will aff ect a fi nal hiring decision.) Are you an exempt volunteer fi reman? (Civil Service Law Section 75) Yes No Have you ever been fi ngerprinted for the purpose of employment? Yes No If Yes, where? When?

(Include Area Code)

Area Date Issued

Initial Professional

Provisional Permanent Certifi cation of Qualifi cation Initial Professional

Provisional Permanent Certifi cation of Qualifi cation Teaching Assistant Temporary/Continuing Level I Level II Level III Pre-Professional Date Issued If you do not have a New York State Teaching Certifi cate, have you made application for one? Yes No Do you have an evaluation of your NYS certifi cate status? Yes (If Yes, enclose a copy) No Other licenses held; type and issuing authority: CERTIFICATION/LICENSE

I hold the New York State Teaching/Administrative Certifi cates(s) described below: P.O. Box 70 4747 Middle Settlement Road

New Hartford, N.Y. 13413-0070

Date

EMPLOYMENT APPLICATION

Last First Middle

City State Zip Code

PLEASE DO NOT USE RETURNS - ALLOW TEXT TO FORMAT AUTOMATICALLY Did You

Name and Location of School Nature of Studies Degree Graduate? College (Undergraduate)*

College (Graduate)*

Vocational/Technical/Trade*

*Provide copy of transcripts (substitute teachers excluded). TEACHING OR ADMINISTRATIVE EXPERIENCE

List most recent experience fi rst. Include any substitute or part time teaching, and indicate as such. Dates

Employed Employer's Name & Address Specifi c Nature of Position Reason for Leaving OTHER WORK EXPERIENCE

Dates

Employed Employer's Name & Address Specifi c Nature of Position Reason for Leaving EDUCATIONAL PREPARATION

Did You

Name and Location of School Nature of Studies Graduate? High school

PLEASE DO NOT USE RETURNS - ALLOW TEXT TO FORMAT AUTOMATICALLY TENURE STATUS

Were you ever appointed on tenure in a public school district in New York? Yes No If YES, complete: Tenure Area: Eff ective Date:

Name and address of school district where tenure was granted: Were you ever dismissed from the school district conferring tenure pursuant to Education Law section 3020-a? Yes No

PROFESSIONAL & SCHOLASTIC ORGANIZATIONS,

MEMBERSHIPS, HONORS

(Exclude organizations, the name or character of which indicates the race, creed, color or national origin of its members.) OTHER SKILLS AND ABILITIES

(e.g. coaching, ability to use sign language)

REFERENCES

List four individuals having personal knowledge of your professional training, ability, experience and personal character. Include the name, address, and telephone number of your last supervisor who we may contact for a personal or professional reference.

Name Position Address & Telephone

May we refer to your present employer? Yes No

May we refer to your former employer(s)? Yes No Placement Folder may be secured from: (Name and Address) PLEASE DO NOT USE RETURNS - ALLOW TEXT TO FORMAT AUTOMATICALLY 1. Have you ever been convicted of a crime or other violation of law, other than a minor traffi c off ense, or is any such case currently pending? Yes No

Have you ever had a conviction for any violation of law sealed or expunged? Yes No Note that the phrase "violation of law" includes not only felonies and misdemeanors, but also quasi-criminal violations such as disorderly conduct. Also, the term "conviction" includes pleas of "guilty" and "no contest." 2. Have you ever had a license or certifi cate of any sort suspended or revoked in any state, or have you ever voluntarily surrendered, temporarily or permanently, any sort of license or certifi cate in any state? Yes No If you answered YES to questions 1 or 2, provide full details on an additional sheet, including the specifi c court or agency involved (e.g., County Court, County of, New York), the address of the court or administrative agency involved, the specifi c violation(s) charged including the date thereof, and the fi nal disposition of the case (e.g.,

"convicted of and fi ned $ "). Note that a conviction or other similar disposition is not necessarily an automatic bar to employment. 3. Have you ever been discharged or asked to resign from a prior position? Yes No 4. Have you ever resigned from a prior position after a complaint was received about you, or while your conduct was under investigation or review, or while disciplinary action was pending against you, or when your employer was likely to take disciplinary action against you? Yes No

If you answered YES to questions 3 or 4, provide full details on an additional sheet, including the specifi c employer involved, the name, address and other contact information of the supervisor(s) involved, the date, the specifi c work infraction(s) charged, and the fi nal disposition of the matter (e.g., "discharged from employment on [date]"). APPLICANT'S STATEMENT

(Give any additional information that you think might be of value in considering you for a position. If necessary, attach an additional sheet of paper.)

I hereby certify that the facts set forth in this application are true and complete to the best of my knowledge. I further acknowledge that any falsifi cation or omission on this form may be a crime, and will be suffi cient cause for disqualifi cation or dismissal, if employed, regardless of when discovered. I give the BOCES the right to investigate all references and to obtain additional job-related information about me. I hereby release from liability for money damages not only the BOCES, but also any of its representatives who investigate the facts set forth herein, as well as anyone disclosing information to them, in connection with this employment application. Applicant's Signature (if mailed) or Name (if emailed*) Date

*Email to OHM BOCES Human Resources confi rms your authorization. If mailed, please return completed application to: Human Resources

Oneida-Herkimer-Madison BOCES

P.O. Box 70 • Middle Settlement Road

New Hartford, New York 13413-0070

Telephone: 315-***-****

To email application, save PDF as your name and send attached file to: ad4m44@r.postjobfree.com EQUAL OPPORTUNITY EMPLOYER

PLEASE DO NOT USE RETURNS - ALLOW TEXT TO FORMAT AUTOMATICALLY

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