Director Vacancy Application | Mid-State Special Education

Position Applying For: *

Personal Information

Name

Email *

Street Address

City and State

Home Phone

Cell Phone

Emergency Contact (Name & Phone) *

I am (check a box) and will provide necessary documentation to validate that I am *

A citizen or national of the United States or

Authorized by the Immigration and Naturalization Service to work in the United States

Have you ever been convicted of a felony? *

Yes

No

NOTE: An applicant for employment is not obligated to disclose sealed or expunged records of conviction or arrest. You are also not obligated to disclose expunged juvenile records of adjudication or arrest.

If yes, when, where, and disposition of the conviction:

What type of experience do you have which would be helpful for the job you are applying for?

Have you ever worked for this cooperative before?

Yes

No

If Yes, when and where:

Date available to start: *

Are you available to work:

Full-Time

Part-Time

List any days or hours you are unable to work:

Please indicate your source of referral:

United States Military Service

Do you have United States Military Experience?

Yes

No

Branch

Present Military status:

Date Entered:

Date Discharged:

Rank at time of Discharge:

Special skills or training from service:

Education

High School Name & Location

Years Completed

Course Work

College Name & Location

Years Completed

Course Work

(Other) Name & Location

Years Completed

Course Work

Employment History

Enter your last four employers, starting with the most current one.

Employer Name

Street Address

Position

Start Date

End Date

Supervisor Name & Title

Phone

Reason for Leaving

Employer Name

Street Address

Position

Start Date

End Date

Supervisor Name & Title

Phone

Reason for Leaving

Employer Name

Street Address

City and State

Position

Start Date

End Date

Supervisor Name & Title

Phone

Reason for Leaving

Employer Name

Street Address

Position

Start Date

End Date

Supervisor Name & Title

Phone

Reason for Leaving

Are there any other places you have worked in addition to those listed above?

Yes

No

Please list any additional experience:

Professional References

List a minimum of three professional references that can provide relevant information with preference given to supervisors under whom you have most recently worked.

Name *

Position *

Email

Phone *

Name *

Position *

Email

Phone *

Name *

Position *

Email

Phone *

Name

Position

Email

Phone

Acknowledgement & E-Signature

By signing below, I understand that misstatements, false representations, or omissions of information in connection with my application for employment can lead to rejection of my application or dismissal from employment, when discovered.

I authorize the Cooperative to analyze the truthfulness of all statements made on this application, complete reference checks from my current and former employers, and others that may provide information regarding my education and experiences. I also authorize criminal background, sex offender, and other checks required by Federal and State government as well as the school code and insurance carrier for the district. I acknowledge that consideration for employment is contingent on the results of these background check(s). In addition, I give my consent for all contacted persons including current and former employers to provide information concerning this application, and I release each such person from liability for providing information to the Cooperative.

I understand that nothing contained in the application, or the granting of an interview is intended to create an employer/employee relationship between the Cooperative and myself either for employment or for the providing of any benefits. No promises regarding employment have been made to me unless made in writing.

I understand that any offers of employment may be contingent upon my taking and successfully passing a drug and/or alcohol test in accordance with Cooperative's policy. If I refuse to submit to testing, refuse to sign the Cooperative's consent form, or test positive, the Cooperative will not employ me.

I hereby attest that all statements made by me are true to the best of my knowledge, and I agree to the terms noted above.

Applicant Signature *

Date *

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