Application for Hiring of Non-District/Part-Time Employees

Program for which I am applying: Location:

Teacher/Tutor Coach

Teaching Assistant Homebound Teacher

Secretary Other

  1. CONTACT AND IDENTIFICATION INFORMATION

Name______

LastFirstMiddleEmail Address

Name must appear exactly as listed on social security card

Present Address______Until______Telephone______

NumberStreetCityState ZipAC Number

Work: Company Name Telephone______

Social Security Number / / Are you a resident of DarlingtonCounty? Yes ______No ______

Are you an employee of the DarlingtonCountySchool District? Yes_____ No_____

Have you applied to the DarlingtonCountySchool District before?Yes_____No_____ If yes, when______

  1. PERSONAL INFORMATION

You are not obligated to discuss information about physical or mental limitations that you believe will not interfere with your capacity to do the job. However, if you want the district to consider special arrangements to accommodate a physical or mental impairment, you may identify that impairment in the space below and suggest the kind of accommodation that you believe would be appropriate.

______

______

Employment:Have you ever been dismissed/non-renewed from any employment?YesNo

If yes, explain______

Convictions:Have you ever been convicted by Federal, State, or other law enforcement authorities or pleaded nolo contendere, for violation of any federal law, state law, county or municipal law, regulation, ordinance, including fraudulent checks? (Do not include any offense or minor traffic violations for which a fine of $30.00 or less was imposed.)

YesNoIf yes, complete below:

Conviction for the

following violationsDateLaw Enforcement AuthorityDisposition

______

______

Through the Family Independence Act of 1995, state agencies are actively recruiting welfare and food stamp recipients. Are you currently receiving AFDC benefits or food stamp? (A yes answer will not disqualify you from employment with the DarlingtonCountySchool District. We must ask this question pursuant to South Carolina Law solely for reporting purposes.) Yes No

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AN EQUAL OPPORTUNITY EMPLOYER

The DarlingtonCountySchool District will provide equal employment opportunities to otherwise qualified individuals without regard to

race, color, religion, gender, age, disability, national origin, or genetic information.

  1. REFERENCES

List below at least three (3) professional references (personal friends and relatives may be used only when professional references are unavailable).

Name / Professional Relationship
Street / Post Office Box / Telephone (Area Code/Number)
City / StateZip
Name / Professional Relationship
Street / Post Office Box / Telephone (Area Code/Number)
City / StateZip
Name / Professional Relationship
Street / Post Office Box / Telephone (Area Code/Number)
City / StateZip
Name / Professional Relationship
Street / Post Office Box / Telephone (Area Code/Number)
City / StateZip
  1. APPLICANT STATEMENT/SIGNATURE

By filing application for employment with the DarlingtonCountySchool District, I understand that any misrepresentation or omission of facts on the application or during the employment process is cause for forfeiture of employment consideration or termination, if employed. I understand that the DarlingtonCountySchool District may contact my previous employers and educational institutions regarding my employment performance and educational background. By my signature below, I herewith authorize the Darlington County School District to request and receive confidential release of documentary materials relating to me, regardless of physical form or characteristics, prepared, owned, used, in the possession of, or retained by: (1) educational institutions I have attended, (2) previous employers of mine, and (3) city, county, state, and federal law enforcement authorities. I herewith grant permission for confidential release of all such information from both employers and educational institutions. Further, I acknowledge that the employment application, transcript, references, and other data, submitted or obtained as part of the employment process, are the property of the DarlingtonCountySchool District and will not be returned to the applicant. Assignments are made in accordance with needs of the School District and are subject to change. Any person signing a contract or work agreement with this School District accepts these conditions.

______

Applicant’s SignatureDate

  1. FOR STATISTICAL PURPOSES AND STATE LAW ENFORCEMENT (SLED) BACKGROUND CHECK

DATE OF BIRTH ______

  1. PLEASE ATTACH A RÉSUMÉ AND A COPY OF YOUR SOCIAL SECURITY CARD ANDDRIVER LICENSEOR PHOTO IDENTIFICATION.

08/02/10

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