PLEASANT VALLEY SCHOOL DISTRICT



PLEASANT VALLEY SCHOOL DISTRICT [pic]

Return application to: Mr. Anthony A. Fadule, Assistant Superintendent

Pleasant Valley District Office

2233 Route 115, Suite 100

Brodheadsville, PA 18322 Phone: (570) 402-1000, Ext. 1209

APPLICATION FOR EMPLOYMENT – General Employment

POSITION DESIRED       DATE OF APPLICATION      

(Please type or print)

How did you learn about us?

| Advertisement | Friend | Walk-In | Other       |

| | | |

| Employment Agency | Relative | Website | |

|Last Name |First Name |Middle Name |

|      |      |      |

|Address |City |State |Zip Code |

|      |      |      |      |

|Telephone Number(s) |Social Security Number |

|      |      |

|E-Mail Address (if available) |

|      |

|EDUCATION |

| |Elementary School |High School |Post-High School |

| |      |      |      |

|School Name and Location | | | |

|Years Completed |4 |5 |

|Describe Course of Study |      |      |

|Describe any specialized training, |      |      |

|apprenticeship, skills, and | | |

|extra-curricular activities. | | |

| |

|FOR ADMINISTRATIVE USE ONLY: |

|Application screened by | | |Date | |

|Interviewed by | | |Date | |

|References checked by | | |Date | |

|Other information | | |Date | |

| |

|FOR PERSONNEL OFFICE USE ONLY: |

|_____ Interview |_____ Date |_____ Payroll Form |

|_____ ACT 34 – PSP |_____ JD |_____ W-4/Act 29/Local EIT |

|_____ ACT 151 – DPW |_____ ADA |_____ Technology Login & Password Request Form |

|_____ Act 114 – FBI |_____ I-9 |_____ Policies |

|_____ PDE-6004 |_____ Identification |_____ Acknowledgement Form |

|_____ Waiver |_____ Health Record |_____ HQ (PPA only) |

| | |_____ CBA |

|EMPLOYMENT EXPERIENCE |

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap, or other protected status.

|Employer |Dates Employed |

|      |      |

|Employer’s Address |

|      |

|Telephone Number(s) |Name of Supervisor |

|      |      |

|Job Title |Work Performed |Salary/Hourly Rate |

|      |      |      |

|Reason For Leaving |

|      |

|Employer |Dates Employed |

|      |      |

|Employer’s Address |

|      |

|Telephone Number(s) |Name of Supervisor |

|      |      |

|Job Title |Work Performed |Salary/Hourly Rate |

|      |      |      |

|Reason For Leaving |

|      |

|Employer |Dates Employed |

|      |      |

|Employer’s Address |

|      |

|Telephone Number(s) |Name of Supervisor |

|      |      |

|Job Title |Work Performed |Salary/Hourly Rate |

|      |      |      |

|Reason For Leaving |

|      |

|Employer |Dates Employed |

|      |      |

|Employer’s Address |

|      |

|Telephone Number(s) |Name of Supervisor |

|      |      |

|Job Title |Work Performed |Salary/Hourly Rate |

|      |      |      |

|Reason For Leaving |

|      |

If you need additional space, please continue on a separate sheet of paper.

State any additional information you feel may be helpful to us in considering your application. You may attach a resume.

     

|Indicate any foreign languages you can speak, read, and/or write. |

| Language(s) |Fluent |Good |Fair |

|Speak       | | | |

|Read       | | | |

|Write       | | | |

|List professional, trade, business, or civic activities and offices held. You may exclude memberships which would reveal sex, race, color, religion, |

|national origin, age, ancestry, handicap, or other protected status: |

| |

|      |

| |

|      |

| |

|      |

| |

|      |

|REFERENCES |

|Give name, address, and telephone number of three references who are not related to you and are not previous employers. |

|      |

|      |

|      |

Have you ever had any job-related training in the United States military? Yes No

If yes, please describe      

Are you currently employed? Yes No

May we contact your present employer? Yes No

On what date would you be available for work?      

Are you available to work Full-time Part-time Shift Work Temporary Substitute

Are you currently on “lay-off” status and subject to recall? Yes No

Can you travel if a job requires it? Yes No

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.

CERTIFICATION AND RELEASE AUTHORIZATION

I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and belief and are made in good faith. This application for employment shall be considered active for a period of time not to exceed one (1) year. Any applicant wishing to be considered for employment beyond this time period should contact the personnel department to update his/her application. I understand that any misrepresentation of information in my application or interview shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3) terminating my employment.

I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records and to respond fully and completely to all questions that officials of the Pleasant Valley School District may ask regarding my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and all claims that I might otherwise have against them with regard to statements made to this school district. I further authorize these officials to investigate my background, now or in the future, to verify the information provided and release from liability all persons and/or entities supplying information regarding my background. However, I do not authorize the production of medical records or other information which would tend to actually identify a disability nor do I authorize inquires which would include information related to any medical condition or medical history. Further, I do not waive any rights which I may have under state or federal law related to my right to challenge the disclosure of unlawful or inaccurate information, whether by the school district or by entities or persons providing such information to the school district, including any and all claims concerning allegations of employment discrimination because of race, color, sex, religion, national origin, ancestry, age, or disability.

______________________________________________________      

Signature of Applicant Date

| |

DOCUMENTS TO INCLUDE WITH APPLICATION

1. A copy of a current* report of Criminal History Record Report (SP-164) must be submitted. (ACT 34 compliance) – The applicant must submit to the PA State Police a $10.00 money order made payable to “Commonwealth of Pennsylvania” or complete on-line at .

2. A copy of a current* Pennsylvania Child Abuse History Clearance (CY113) must be submitted. (ACT 151 compliance) – the applicant must submit a $10.00 money order made payable to “Department of Public Welfare.”

3. A copy of a current* Act 114 Federal Bureau of Investigation (FBI) Federal Criminal History record must be submitted (ACT 114 compliance). The Pennsylvania Department of Education (PDE) contracted with Cogent Systems to manage this program for the Commonwealth. The applicant will pay a $28.75 fee. The registration process is available online 24 hours/day, seven days per week at pa.. Telephonic registration is available at 1-888-439-2486 Monday through Friday, 8:00 a.m. to 6:00 p.m. EST. 

4. Arrest/Conviction Report and Certification Report and Certification Form (Act 24 – Form PDE-6004).

* Current is defined as less than one (1) year from the date of issue.

Prior to commencement of duties, individuals must do the following:

5. Complete the Employment Eligibility Verification Form (Form I-9). You must include copies of the listed methods of identification.

6. Obtain and have a physician complete the School Personnel Health Record.

Pursuant to all applicable federal and state laws and regulations, the Pleasant Valley School District does not discriminate on the basis of race, color, religion, national origin/ethnicity, gender, age, sexual orientation, or any non-job related handicap or disability in employment practices and hires only individuals lawfully authorized to work in the United States of America.

Please direct inquiries regarding Title IX, Title IV, and Section 504 policies to:

Mr. Anthony A. Fadule, Assistant Superintendent

Pleasant Valley School District

2233 Route 115, Suite 100

Brodheadsville, PA 18322

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