Mcminnville Public Schools

McMinnville Public Schools

800 NE Lafayette Av

McMinnville OR 97128

Phone: (503) 565-4000

Fax: (503) 565-4042 www.msd.k12.or.us

McMinnville School District provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, genetics, marital status or sexual orientation. For more information see District Policy GBA-Equal Employment Opportunity.

Please complete entire application. A resume and letters of recommendation may be included.

Name:

Last First Middle (first name preferred)

Address:

Street City State Zip

Phone:

Home Cell

EDUCATIONAL RECORD

Starting with high school, list schools attended and their locations:

School / Dates Attended
From To / Degree / Course of Study/
Number of College Credits

REFERENCES (not a relative):

Name: Position:

Address:

Street City State Zip

Phone:

Name: Position:

Address:

Street City State Zip

Phone:

Name: Position:

Address:

Street City State Zip

Phone:

Have you passed a paraprofessional assessment test? No ___ Yes ___

Have you been fingerprinted for another school district? No Yes If so, where? ______

EMPLOYMENT RECORD

List all previous employment for the last 10 years. List most recent first. Attach additional sheets if necessary.

1. Employer Complete Address

Phone Type of Business

Supervisor Your Job Title

Your Duties

Number of Years From (month/year) To (month/year)

Reason for Leaving

2. Employer Complete Address

Phone Type of Business

Supervisor Your Job Title

Your Duties

Number of Years From (month/year) To (month/year)

Reason for Leaving

3. Employer Complete Address

Phone Type of Business

Supervisor Your Job Title

Your Duties

Number of Years From (month/year) To (month/year)

Reason for Leaving

Please use the key to indicate experience or training in any of the following specific areas:

Key: E = Experience T = Training T/E = Both

Secretarial Applicants

___Accounting ___Receptionist

___Accounts Payable ___Secretary

___Accounts Receivable ___Supervising Employees

___Bookkeeping ___Supervising Student Workers

___Multi-line Phone System ___Filing

___Ten-Key by Touch ___Mailing Machine

___Payroll ___Purchasing

___Word Processing ___Spreadsheets/Database

Please list computer programs with which you are familiar:

Please provide any additional comments you wish to make concerning your qualifications:

Custodial/Maintenance/Grounds Applicants

___Carpentry ___HVAC/Boiler

___Carpet Cleaning/Repair ___Industrial Cleaning

___Computer Skills ___Landscaping/Irrigation

___Concrete Flatwork ___Mechanical

___Custodial ___Painting

___Floor Waxing ___Groundskeeping

___Plumbing ___Electrical

___Warehouse ___Use/Storage of Cleaning Supplies

___Hazardous Materials/MSDS Training

Please provide any additional comments you wish to make concerning your qualifications:

Please use key to indicate experience or training in any of the following specific areas:

Key: E = Experience T = Training T/E = Both

Technology Applicants

___ Install and format new computer hardware ___ Repair and maintenance of PC computers

___ Programming ___ Troubleshoot and diagnose network problems

Educational Assistant/Special Education Assistant/Library Assistant Applicants

___ Library/Media Centers ___ Word Processing

___ Campus Supervision ___ Playground Supervision

Describe any training you have had working with K-12 students:

What abilities and experiences have you had working with individual students and groups of students in reading and math?

Describe your experience with:

Alternative education students:

Children with disabilities:

ELL, Migrant or bilingual students:

Please provide any additional comments you wish to make concerning your qualifications:

Food Service Applicants

___ Baking ___ Menu Planning

___ Cashier ___ Nutrition

___ Computer Skills ___ Ordering Food/Supplies

___ Customer Service ___ Quantity Food Preparation (50 or more)

___ Dishwashing ___ Supervising others

Do you have a current food handler’s card for Oregon? ___ Yes ___ No

Have you been employed in food service areas? __ Yes __ No If yes, describe the work and responsibilities:

I verify that all information on this employment application is true and complete. I understand that any misrepresentation, falsification or omission on this application or on other documents submitted to the school district will be sufficient cause for this application not to be considered by the district, or for discharge if I have been employed.

Signature: ______Date:______

Name (Printed): ______Revised 5-2017

McMinnville School District

800 NE Lafayette Av

McMinnville OR 97128

Criminal History Verification of Applicants

Please type or print clearly, as appears on your legal identification:

Legal Name: ______

(Last Name) (First Name) (Middle Name)

List Other Names Previously Used: ______Phone #:______

(includes Maiden Name)

Social Security #:______DOB:______Gender: Male___ Female___

Driver License/Identification Card No.: ______State: ______

Your social security number will only be used as stated below. State and federal laws protect the privacy of your records.

Address______

Street Apt # City State Zip

A.  Have you EVER been convicted of a sex-related crime? __ *Yes __ No

1.  If yes, was the conviction in Oregon or another state? Please specify state : ______

2.  If yes, did the crime involve force to minors? __ *Yes __ No

B.  Have you EVER been convicted of a crime involving violence or threat of violence? __ *Yes __ No

1.  If yes, was the conviction in Oregon or another state? Please specify state: ______

C.  Have you EVER been convicted of a crime involving criminal activity in drugs or alcoholic beverages? __ *Yes __ No

1.  If yes, was the conviction in Oregon or another state? Please specify state: ______

D.  Have you EVER been convicted of any other crime except a minor traffic violation?(Includes Traffic Crimes) __ *Yes __ No

E.  Have you been arrested within the last three years for a crime for which there has not yet been an acquittal or dismissal? __ *Yes __ No

*If you answered ‘Yes’ to any of the above questions, please provide an explanation here. If you need more space, please use the back of this page.

Advisory: A check of the applicant’s criminal history will be made by the MSD to verify the responses to the preceding questions. I hereby grant to the school district permission to check civil or criminal records to verify any statement made on this form. Regardless of whether the applicant grants consent, the school district will conduct a criminal offender record check of applicants for all prospective school employees and volunteers working with or around children. The applicant is entitled to review his/her criminal history for inaccurate or incomplete information. Discrimination by an employer on the basis of arrest records alone may violate federal civil rights law. The applicant may obtain further information concerning the applicant’s rights by contacting the Bureau of Labor and industries, Civil Rights Division, State office Building, Suite 1070, Portland, Oregon 97323, telephone (503) 731-4075.

I acknowledge reading and the receipt of this notice.

Applicant/Volunteer Signature: ______Date: ______