Employment App | Mid-State Special Education

Position Applying For: *

Date

Personal Information

Full Name *

Email *

Street Address *

City, State & Zip Code *

Phone

Emergency Contact (Name & Phone) *

(Check a Box) & I 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

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

Degree Earned

College Name & Location

Years Completed

Degree Earned

(Other) Name & Location

Years Completed

Degree Earned

Employment History

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

Employer Name

Address

Email

Position

Start Date

End Date

Supervisor Name & Title

Phone

Reason for Leaving

Employer Name

Address

Email

Position

Start Date

End Date

Supervisor Name & Title

Phone

Reason for Leaving

Employer Name

Address

Email

Position

Start Date

End Date

Supervisor Name & Title

Phone

Reason for Leaving

Employer Name

Address

Email

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

Include three professional references who supervised your previous work (principals, supervisors, superintendents).

Name *

Address *

Email

Phone *

Name *

Address *

Email

Phone *

Name *

Address *

Email

Phone *

Licenses

Please complete the following section if applying for a licensed position.

Illinois State Board of Education Professional Educator License (PEL), if applicable

Yes

No

IEIN:

Illinois Department of Financial and Professional Regulation License, if applicable

Yes

No

IDFPR:

National Provider Identifier, if applicable

Yes

No

NPI:

THIS SECTION MUST BE COMPLETED AS PART OF THE APPLICATION PROCESS. PLEASE MAKE CERTAIN THAT YOU ANSWER ALL OF THE QUESTIONS TRUTHFULLY. OMISSION OR FALSIFICATION OF ANY CRIMINAL INFORMATION WILL BE GROUNDS FOR IMMEDIATE DISMISSAL

Have you ever been convicted of an offense other than a minor traffic violation? *

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:

Have you ever been convicted of, had adjudication withheld, pled no contest to, or entered a pretrial intervention program for a misdemeanor or felony criminal charge? *

Yes

No

Have you ever been the subject of an indicated report by DCFS or similar state agency? *

Yes

No

Have you ever been suspended without pay, or dismissed from employment, or resigned while an investigation was in progress for possible disciplinary action?

Yes

No

If YES, please explain when and where:

Acknowledgement & E-Signature

By signing below, I understand that the information provided is true and correct, and that any misstatements or omission of material facts in the application or the hiring process may result in discontinuing of the hiring process or termination of employment, no matter when discovered. I agree that the district shall not be held liable in any respect if my employment is terminated because of false statements, answers or omissions made by me in this application.

I authorize the school district 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 a criminal background, sex offender, and other checks required by Federal and State government and the school code. 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 school district.

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

Applicant Signature *

Date *

Website/URL