Our District: Job Applications

Teacher Associate

by Kris Van Pelt

November 20, 2005

401.4 �Exhibit D

BOARD OF DIRECTORS

OGDEN COMMUNITY SCHOOL DISTRICT

TEACHER ASSOCIATE APPLICATION FORM

Please complete all information and forward to:

Superintendent

Ogden Community School District

Box 250

Ogden, IA 50212

PERSONAL INFORMATION

Last Name_____________________ First_________________ Middle_________________

Business Address_________________________________________Telephone___________

City ________________________________State_________________Zip_______________

Home Address ____________________________________________Telephone__________

City ________________________________State__________________Zip______________

Yes No

___ _____ Are you trained in first aid techniques?

Training ____________________________________________

___ _____ Are you trained in CPR?

Training _____________________________________________

Were you honorably discharged from the United States military forces after service between the periods of December 7, 1941 and December 31, 1946, or June 25, 1950 to January 31, 1955, or August 5, 1964 to May 7, 1975, or during the Persian Gulf conflict? _________Yes ________No

Please complete if you are claiming a veteran's preference:

Active Duty/Reserve Duty

Branch_______________________Period of Duty_______________________

Location of Duty________________Rank at Discharge___________________

Has there ever been a judicial or administrative finding that you have abused or mistreated a minor or child? (If yes, attach explanation.) ________Yes __________No

EMPLOYMENT HISTORY

List all experience in chronological order.

NAME LOCATION POSITION FROM /TO SUPERVISOR PHONE

______________________________________________________________________________

_______________________________________________________________________________

PROFESSIONAL PREPARATION

INSTITUTION LOCATION MAJOR/MINOR DEGREE

_______________________________________________________________________________

REFERENCE (LIST AT LEAST TWO)

Name Position Res.Phone Bus.Phone

_______________________________________________________________________________

I certify that the information given in this application (and accompanying resume, if any,) is true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application, and I authorize Ogden Community School District to contact my references and prior employers, and release from all liability or responsibility all persons or corporations requesting or supplying information. I understand that giving false, incomplete, or misleading information in my application or inter-view may result in withdrawal of my application for consideration or in discharge.

I understand that the Ogden Community School District will do a criminal records and child abuse check on me.

If my duties will include driving a school vehicle for which I need a CDL license and if the vehicle transports 16 or more persons or the vehicle weights 26,001 pounds or more, I have been informed of the requirement to submit to a drug test prior to being employed by the District to perform a safety-sensitive function. I consent to submit to the District�s drug and alcohol testing program. I also understand that if I have a positive drug test, I will not be considered further for employment by the District.

I UNDERSTAND THAT I MAY NOT BE EMPLOYED UNTIL APPROVAL IS GIVEN BY THE DISTRICT�S

BOARD OF DIRECTORS.

Signed_________________________________________________Date_________________

The Ogden Community School District provides equal employment opportunities to all persons regardless of race, color, national origin, creed, religion, marital status, parental status, age or disability. Questions regarding compliance with equal employment opportunities should be directed to the Superintendent at Box 250, Ogden, Iowa 50121, telephone number (515) 275-2894.