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 | | | |

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REFERENCES (Provide three with contact information)

|NAME |Telephone |E-mail Address |

| | | |

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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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