PLEASANT VALLEY SCHOOL DISTRICT

Return application to: Mr. Anthony A. Fadule, Assistant Superintendent

Pleasant Valley District Office

2233 Route 115, Suite 100

Brodheadsville, PA 18322 Phone: (570) 402-1000, Ext. 1209

APPLICATION FOR EMPLOYMENT – General Employment

POSITION DESIRED DATE OF APPLICATION

(Please type or print)

How did you learn about us?

Advertisement / Friend / Walk-In / Other
Employment Agency / Relative / Website
Last Name
/ First Name
/ Middle Name
Address
/ City / State / Zip Code
Telephone Number(s) / Social Security Number
E-Mail Address (if available)

EDUCATION

Elementary School / High School / Post-High School
School Name and Location
Years Completed / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12
Diploma/Degree
Describe Course of Study
Describe any specialized training, apprenticeship, skills, and extra-curricular activities.
FOR ADMINISTRATIVE USE ONLY:
Application screened by / Date
Interviewed by / Date
References checked by / Date
Other information / Date
FOR PERSONNEL OFFICE USE ONLY:
_____ Interview / _____ Date / _____ Payroll Form
_____ ACT 34 – PSP / _____ JD / _____ W-4/Act 29/Local EIT
_____ ACT 151 – DPW / _____ ADA / _____ Technology Login & Password Request Form
_____ Act 114 – FBI / _____ I-9 / _____ Policies
_____ PDE-6004 / _____ Identification / _____ Acknowledgement Form
_____ Waiver / _____ Health Record / _____ HQ (PPA only)
_____ CBA

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap, or other protected status.

Employer / Dates Employed
Employer’s Address
Telephone Number(s) / Name of Supervisor
Job Title / Work Performed / Salary/Hourly Rate
Reason For Leaving
Employer / Dates Employed
Employer’s Address
Telephone Number(s) / Name of Supervisor
Job Title / Work Performed / Salary/Hourly Rate
Reason For Leaving
Employer / Dates Employed
Employer’s Address
Telephone Number(s) / Name of Supervisor
Job Title / Work Performed / Salary/Hourly Rate
Reason For Leaving
Employer / Dates Employed
Employer’s Address
Telephone Number(s) / Name of Supervisor
Job Title / Work Performed / Salary/Hourly Rate
Reason For Leaving

If you need additional space, please continue on a separate sheet of paper.

State any additional information you feel may be helpful to us in considering your application. You may attach a resume.

Indicate any foreign languages you can speak, read, and/or write.
Language(s) / Fluent / Good / Fair
Speak
Read
Write
List professional, trade, business, or civic activities and offices held. You may exclude memberships which would reveal sex, race, color, religion, national origin, age, ancestry, handicap, or other protected status:

REFERENCES

Give name, address, and telephone number of three references who are not related to you and are not previous employers.
1. 
2. 
3. 

Have you ever had any job-related training in the United States military? Yes No

If yes, please describe

Are you currently employed? Yes No

May we contact your present employer? Yes No

On what date would you be available for work?

Are you available to work Full-time Part-time Shift Work Temporary Substitute

Are you currently on “lay-off” status and subject to recall? Yes No

Can you travel if a job requires it? Yes No

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.

CERTIFICATION AND RELEASE AUTHORIZATION

I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and belief and are made in good faith. This application for employment shall be considered active for a period of time not to exceed one (1) year. Any applicant wishing to be considered for employment beyond this time period should contact the personnel department to update his/her application. I understand that any misrepresentation of information in my application or interview shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3) terminating my employment.

I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records and to respond fully and completely to all questions that officials of the Pleasant Valley School District may ask regarding my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and all claims that I might otherwise have against them with regard to statements made to this school district. I further authorize these officials to investigate my background, now or in the future, to verify the information provided and release from liability all persons and/or entities supplying information regarding my background. However, I do not authorize the production of medical records or other information which would tend to actually identify a disability nor do I authorize inquires which would include information related to any medical condition or medical history. Further, I do not waive any rights which I may have under state or federal law related to my right to challenge the disclosure of unlawful or inaccurate information, whether by the school district or by entities or persons providing such information to the school district, including any and all claims concerning allegations of employment discrimination because of race, color, sex, religion, national origin, ancestry, age, or disability.

______

Signature of Applicant Date

DOCUMENTS TO INCLUDE WITH APPLICATION

1.  A copy of a current* report of Criminal History Record Report (SP-164) must be submitted. (ACT 34 compliance) – The applicant must submit to the PA State Police a $10.00 money order made payable to “Commonwealth of Pennsylvania” or complete on-line at https://epatch.state.pa.us.

2. A copy of a current* Pennsylvania Child Abuse History Clearance (CY113) must be submitted. (ACT 151 compliance) – the applicant must submit a $10.00 money order made payable to “Department of Public Welfare.”

3.  A copy of a current* Act 114 Federal Bureau of Investigation (FBI) Federal Criminal History record must be submitted (ACT 114 compliance). The Pennsylvania Department of Education (PDE) contracted with Cogent Systems to manage this program for the Commonwealth. The applicant will pay a $28.75 fee. The registration process is available online 24 hours/day, seven days per week at www.pa.cogentid.com.Telephonic registration is availableat1-888-439-2486 Monday through Friday, 8:00 a.m. to 6:00 p.m. EST.

4.  Arrest/Conviction Report and Certification Report and Certification Form (Act 24 – Form PDE-6004).

* Current is defined as less than one (1) year from the date of issue.

Prior to commencement of duties, individuals must do the following:

5.  Complete the Employment Eligibility Verification Form (Form I-9). You must include copies of the listed methods of identification.

6.  Obtain and have a physician complete the School Personnel Health Record.

Pursuant to all applicable federal and state laws and regulations, the Pleasant Valley School District does not discriminate on the basis of race, color, religion, national origin/ethnicity, gender, age, sexual orientation, or any non-job related handicap or disability in employment practices and hires only individuals lawfully authorized to work in the United States of America.

Please direct inquiries regarding Title IX, Title IV, and Section 504 policies to:

Mr. Anthony A. Fadule, Assistant Superintendent

Pleasant Valley School District

2233 Route 115, Suite 100

Brodheadsville, PA 18322