Circle Unified School District 375
901 Main, PO Box 9, Towanda, KS 67144
(316) 541-2577
(316) 536-2249 (fax)
Date of Application *
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Applicant's Name *
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Address *
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City,State,Zip *
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Home Phone Number *
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Work Phone Number *
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Email Address *
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SSN *
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In order of preference, please indicate the position(s) which you are applying for:
Position 1 *
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Position 2
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Position 3
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Are you currently employed? *
Employer
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Date you can start *
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Employment Record
List most recent first. Please explain any gaps in employment.
Name of Employer 1 *
Employer's Address and Phone Number
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Supervisors Name 1 *
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Employment Position 1 *
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Date Inclusive 1 *
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Reason for Leaving 1 *
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Name of Employer 2
Employer's Address and Phone
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Supervisors Name 2
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Employment Position 2
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Dates Inclusive 2
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Reason for Leaving 2
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Name of Employer 3
Employer's Address and Phone
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Supervisors Name 3
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Employment Position 3
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Dates Inclusive 3
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Reason for Leaving 3
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Have you ever been convicted of a felony? *
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List any civic organizations and activities that you are involved with
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Education and Training
Name and Location of Institution 1
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Number of Years Attended 1
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Degree or Diploma 1
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Date Received 1
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Name and Location of Institution 2
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Number of Years Attended 2
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Degree or Diploma 2
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Date Received 2
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Name and Location of Institution 3
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Number of Years Attended 3
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Degree or Diploma 3
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Date Received 3
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Any additional remarks that you think might strengthen your application, such as special training:
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References
Please do not use relatives - List three
Name 1 *
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Address 1 *
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Phone Number 1 *
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Official Position 1 *
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Name 2 *
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Address 2 *
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Phone Number 2 *
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Official Position 2 *
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Name 3 *
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Address 3 *
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Phone Number 3 *
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Official Position 3 *
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Information provided
I certify that all the information provided by me in this application is true and complete. I understand that any misstatement, falsification, or omission of information is grounds for refusal to hire, or if I am hired and the same is discovered thereafter, termination. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or other information, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability for any damages that may result from furnishing such information to you.

I authorize any background checks by any third party.
I authorize you to request, receive, and verify all infomation given on this application and I release you from all damages that may result from you doing so.

I authorize you to conduct a criminal background investigation using any and all methods necessary to successfully complete such investigation and I release
you from all liability for any damages that may result from your doing so.

I understand that if I am offered provisional employment in the school district that my fingerprints may be taken and a request made for a state and national criminal background check. I further understand that if the results of this criminal history check reveals that I have been convicted of any offense or any attempt to commit any offense specified in K.S.A. 1999 Supp. 72-1397 and amendments thereto that my employment may be terminated without further proceedings and without reference to any other law or employment agreement.

Signature *
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Date *
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Notice of Non‐Discrimination 
Circle USD 375 does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups.  The following person has been designated to handle inquiries regarding the non‐discrimination policies: Don Potter, Superintendent, 901 Main, PO Box 9, Towanda, KS  67144, 316‐541‐2577 or dpotter@usd375.org
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