Employment Form

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APPLICATION FOR EMPLOYMENT

GRANT PUBLIC SCHOOLS
12192 S. Elder Avenue
Grant, MI 49327

Date_____________________

NAME ____________________________________________Soc. Sec. No.__________________
Last First Middle

PRESENT ADDRESS______________________________________________________________
No Street City State Zip

TELEPHONE_(_____)____________________
area code

ARE YOU A CITIZEN OF THE UNITED STATES, A LAWFUL PERMANENT RESIDENT, OR OTHERWISE AUTHORIZED FOR WORK IN THE UNITED STATES?

SPECIFIC POSITION DESIRED ________________________FULL TIME_____PART TIME_____

Were you previously employed by us? __________ If yes, when?__________________

If your application is considered favorably, on what date will you be available for work?_________

Are there any other experiences, skills, or qualifications which will be of special benefit in the job for which you are applying? (Applicant should not list any information that Federal and/or State law precludes obtaining in the pre-employment stage)

RECORD OF EDUCATION

School	Name and Address of School	Course of Study	Check Last Year Completed				Did You Graduate?	List Diploma or Degree
High School			1	2	3	4	Yes No
College			1	2	3	4	Yes No
Other (Specify)			1	2	3	4	Yes No

MILITARY SERVICE RECORD

Were you in U.S. Armed Forces? Yes No If Yes, what Branch?____________

Did you receive any training in the U.S. Armed Forces that is relevant to the position applied for?

________________________________________________________________________________

LIST BELOW PRESENT AND PAST EMPLOYMENT, BEGINNING WITH YOUR MOST RECENT

Name and Address of Company and Type of Business	From		To		Weekly Starting Salary	Weekly Last Salary	Reason for Leaving	Name of Supervisor
	Mo.	Yr.	Mo.	Yr.

	Describe the work you did:__________________________________________________________ ________________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
Telephone:

Name and Address of Company and Type of Business	From		To		Weekly Starting Salary	Weekly Last Salary	Reason for Leaving	Name of Supervisor
	Mo.	Yr.	Mo.	Yr.

	Describe the work you did:__________________________________________________________ ________________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
Telephone:

Name and Address of Company and Type of Business	From		To		Weekly Starting Salary	Weekly Last Salary	Reason for Leaving	Name of Supervisor
	Mo.	Yr.	Mo.	Yr.

	Describe the work you did:__________________________________________________________ ________________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________
Telephone:

I hereby give permission to contact the employers listed above concerning my prior work experience.

_________________________________________
Signed

If there is a particular employer(s) you do not wish us to contact, please indicate which one(s):

PERSONAL REFERENCES (Not former employers or relatives.)

Name and Occupation	Address	Phone Number

HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR - OTHER THAN A MINOR TRAFFIC VIOLATION? YES NO.

IF YES, GIVE DETAILS___________________________________________________________

_______________________________________________________________________________

ARE THERE ANY FELONY CHARGES PENDING AGAINST YOU? YES NO

IF YES, GIVE DETAILS____________________________________________________________

________________________________________________________________________________

I certify that the information and answers I provided on this employment application are true and complete to the best of my knowledge. I also agree that any false information, misrepresentations, or omissions may disqualify me from further consideration for employment or may result in discharge if hired, without regard to either my knowledge or the inaccuracy, the length of my employment, or the seriousness of the inaccuracy.

I authorize the District to conduct such background investigations, except as noted above, as it deems necessary in arriving at an employment decision. I release the District and all companies, agencies, schools, and persons contacted from all liability and responsibility for providing, receiving, or acting on such information. I further agree to cooperate in any such investigation.

I understand that if I have a protected disability that affects my ability to perform the position, I may ask the District to attempt to make accommodation as required by law. I must make my request in writing to the District as soon as possible and no later than 182 days after the date I know or reasonably should know that accommodation is needed.

I agree to conform to the rules and regulations of the District. No person other than the Superintendent has authority to offer employment for any specified period or to make any representations or agreement contrary to the foregoing. Moreover, no such agreement by the Superintendent will be enforceable unless the document is in writing, dated, signed by the Superintendent, and has been formally adopted by the School Board.

_____________________________________ ___________________________

SIGNATURE DATE

DRUG TESTING CERTIFICATION:

I hereby give my consent for the District, through an authorized testing service of its choice, to collect blood, urine, hair, or saliva samples, or other fluid or tissue samples from me and to conduct any other necessary medical tests to determine the presence of alcohol, drugs, or controlled substances, and I hereby release the District from any liability arising out of such tests or its results. Further, I give my consent for the release of the test results and other relevant medical information to authorized District officials for appropriate review. I acknowledge that remaining free of illegal drug use is a condition of my employment.

_________________________________           ____________________________
SIGNATURE                                                     DATE

ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE SPECIFIC POSITION FOR WHICH YOU ARE APPLYING WITH ACCOMMODATION OR WITHOUT ACCOMMODATION ?

CERTIFICATION OF ABILITY TO PERFORM POSITION REQUIREMENTS

I certify that to the best of my knowledge I am able to perform the requirements of the position I seek. I have received a copy of the description for the position and understand the requirements. I acknowledge that this position requires (for example: lifting, sitting, standing, turning, etc.)

I also understand that if I have a protected disability that affects my ability to perform the job I seek, I may ask the School District to attempt to make a reasonable accommodation for it. I must make my request in writing to the District's Human Resource Department as soon as possible and no later than 182 days after the date I know or reasonably should know that accommodation is needed.

__________________________________            ________________________
APPLICANT'S SIGNATURE                                 DATE

Employment opportunities are open to all without regard to race, color, sex, age, religion, national origin, marital or veteran status, or height, weight, or non-disqualifying disability or handicap.

THIS APPLICATION SHOULD BE MAILED TO THE ADDRESS ON THE FRONT PAGE OF THE FORM

ALL APPLICATIONS WILL BE KEPT ON FILE FOR ONE FULL YEAR. AFTER THAT TIME THE APPLICANT MUST RE-APPLY IF STILL INTERESTED IN EMPLOYMENT WITH THE SCHOOL DISTRICT.

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