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           BASIN ELEMENTARY SCHOOLZ:\Basin\Bear Clipart.pngZ:\Basin\Bear Clipart.png

CUSTODIAN CLASSIFIED STAFF APPLICATION

PO BOX 128 BASIN MT 59631

PHONE: (406) 225-3211

 

Date of Application:_______________

PERSONAL DATA:

Name:______________________________________________________________________________

Address:____________________________________________________________________________

Phone:(_      )______________________  Email:___________________________________________

Date Available: ___________________________       SSN: _________________________

 

Are you a US Citizen?     Yes: ______   No: _____

If no, are you authorized to work in the US?   Yes: ______      No: ______

Have you ever worked for this School?    Yes: ______   No: ______

If so, when? ____________________________________________

EDUCATION:

High School: _______________________  Address: _______________________________________

From: ______ to ______ Did you graduate?  Yes: _____  No: _____  Degree: __________________

College: __________________________  Address: _________________________________________

From: ______ to _______ Did you graduate?  Yes: ______ No: _____ Degree: _________________

Other: ___________________________ Address: __________________________________________

From: ______ to _______ Did you graduate? Yes: ______ No : ______ Degree: _______________

REFERENCES:

Please list 3 professional references

Full Name: ________________________________ Relationship: ____________________________

Company: ________________________________ Phone #: _________________________________

Address: ____________________________________________________________________________

Full Name: ________________________________ Relationship: ____________________________

Company: ________________________________ Phone #: _________________________________

Address: ____________________________________________________________________________

Full Name: ________________________________ Relationship: ____________________________

Company: ________________________________ Phone #: _________________________________

Address: ____________________________________________________________________________

PREVIOUS EMPLOYMENT: Most Recent First

Company: ___________________________________  Phone #: _____________________________

Address: ______________________________________ Supervisor: __________________________

Job Title: ______________________________________ From __________ to ___________

Responsibilities: ____________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Reason for leaving: __________________________________________________________________

May we contact your previous supervisor for a reference?        Yes: ______        No: _______

Company: ___________________________________  Phone #: _____________________________

Address: ______________________________________ Supervisor: __________________________

Job Title: ______________________________________ From __________ to ___________

Responsibilities: ____________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Reason for leaving: __________________________________________________________________

May we contact your previous supervisor for a reference?        Yes: ______        No: _______

Company: ___________________________________  Phone #: _____________________________

Address: ______________________________________ Supervisor: __________________________

Job Title: ______________________________________ From __________ to ___________

Responsibilities: ____________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Reason for leaving: __________________________________________________________________

May we contact your previous supervisor for a reference?        Yes: ______        No: _______

PREFERENCES:

Attach a copy of your DD 214.

Are you claiming Veteran’s Preference?_________ Are you a disabled Veteran?_________

CHILD SAFETY: 

Have you, within the past seven years, been released from prison or been convicted of any form of violence, such as assault, rape, child abuse, child molestation, extortion, blackmail, or any offense that involves drugs, embezzlement, fraud, stealing, or robbery? Yes : _______   No: _________

If yes, please attach a separate sheet explaining the nature, place and date of the crime.

Do you consent to a fingerprint/background check as required by state and federal laws for employment in a school district?

_________ Initial here to indicate you understand.

 RELEASE OF LIABILITY I hereby authorize Basin Public Schools to inquire as to my record with any or all of my former and/or current employers or references with no liability arising there from. I thereby guarantee the above information is true. I understand misrepresentation or omission of facts called for is cause for dismissal.

________________________________________ Signature ______________________________ Date

Supplemental Items Attached: