MONTGOMERY COUNTY R-II SCHOOL DISTRICT
MONTGOMERY COUNTY R-II SCHOOL DISTRICT
418 NORTH HIGHWAY 19
MONTGOMERY CITY, MO 63361
[pic]573-564-2278[pic]
573-564-6182 fax
Application for Support Staff Position
SOCIAL SECURITY NUMBER __________________________________ DATE__________________________
Name:
Last Name First Name Middle Initial
Present Address: _________________________________________________________________________________
Street City State Zip Code
Permanent Address:_____________________________________________________________
Street City State Zip Code
Telephone Number(s)__________________________________Cell Phone #______________________________
E-Mail Address:_______________________________________________________________________________
Position Desired:
_____________________________________________________________________________________________
Do you need accommodations to perform the tasks required of this position? ____YES ____NO
If “YES”, please explain._______________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________
Education:
| | |Dates Attended |Degree/Diploma |Graduation Date |
| |School Attended | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
REFERENCES (Provide three with contact information)
|NAME |Telephone |E-mail Address |
| | | |
| | | |
| | | |
CRIMINAL HISTORY/VERIFICATION AUTHORIZATION
Have you ever been convicted of, pleaded guilty, or, entered a plea of contest to any violation against a child, or any other criminal violation, other than a minor traffic violation? ____YES ____NO
IF “YES”, please explain. If additional space is needed, include on a separate paper and attach.
_____________________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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I understand that any false or misleading information in this application may result in refusal to employ me or may result in my termination. I hereby authorize the Montgomery County R-II School District to receive copies of or to inspect any child abuse conviction records or criminal records relating to me. I hereby authorize any and all previous places of employment to provide information to the Montgomery County R-II School District concerning my employment with their District/Agency/Business and indemnify and hold harmless the previous employers listed in this application for providing said truthful information.
_________________________________ ______________________________
SIGNATURE OF APPLICANT DATE
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