Application for Employment

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Scot Potter
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1 Application for Employment Classified Personnel Green Hills Area Education Agency P.O. Box 1109 Council Bluffs, IA (in Iowa) Fax: Applicants for all positions are considered without regard to race, color, national origin, gender, disability, religion, creed, age, sexual orientation or gender identity. Name Date Address City State Zip Home Phone Cell phone address Position applied for Best time/method to contact you (i.e. phone, ) May we contact you at work? If yes, work number After a review of the job description for this position, can you perform the essential functions of this job with or without reasonable accommodations? If hired, can you give written evidence of a right to work in this country (i.e. social security card, birth certificate, etc.)? If you are offered a position, the offer will be conditioned upon your successful completion of a preplacement physical examination. Are you willing to take such an examination? Are you willing to work overtime if required? Have you ever been convicted of a felony? If yes, attach a complete written statement. (Conviction will not necessarily disqualify an applicant form employment.) Did you serve in the United States military during any of the following periods? June 25, 1950 to January 31, 1955; August 5, 1964 to May 7, 1975; August 2, 1990 to present If you answered yes to the above question, were you honorably discharged?

2 Employment History: List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below. Comments (including explanation of any gaps in employment)

3 Skills and Qualifications Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work with our Agency. Educational Background A. List last three (3) schools attended, starting with the last one; B. List number of years completed; C. Indicate degree or diploma earned, if any; D. Major and E. Minor field of study (if applicable). A. School B. No. Years Completed C. Degree Diploma D. Major E. Minor References List name and telephone number of three (3) business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you. May we contact? Name Address Yrs. Known Reference Type List additional information you believe pertinent to this application for employment.

4 Green Hills Area Education Agency is an Affirmative Action/Equal Employment Opportunity. No question on this application is used for the purpose of limiting or excluding any applicant s consideration for employment on a basis prohibited by local, stat or federal law. An Equal Employment Opportunity/Affirmative Action Plan has been developed and implemented. A grievance procedure process is in place. The Agency s Affirmative Action Coordinator is Lori Kinyon. If you have questions about the plan, the grievance process, or any other EEO/AA concerns, contact Lori Kinyon, Director of Human Resources Green Hills Area Education Agency 230 N. Pine, Creston IA Please Read Before Signing I hereby affirm that the information provided on this application and accompanying résumé is true and complete. I also agree and understand that any falsified information or omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I authorize a thorough investigation of my employment including reference checks with current and past employers. I also agree to cooperate in such investigation, and release from all liability or responsibility all persons and corporations requesting or supplying such information. Anytime after a conditional offer of employment or during employment, if hired, I authorize any physician or health care provider to release information advising the Agency (1) whether I am currently able to perform the specified job for which I am being considered or employed, with or without reasonable accommodations, and the basis for such conclusions; and (2) whether I can perform the job without posing a direct threat to the health of safety of myself or others. I understand that according to federal law all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identity and U.S. citizen status, or, if aliens, their legal authorization to work in the United States. As a consequence, I understand that any offer of employment would be contingent upon my ability to produce the required documentation within the time period required by law. I understand that neither this document nor any other letter from the employer constitute an employment agreement unless a specific document to that effect is executed by the employer and myself in writing. I hereby acknowledge that I have read and understand the above statements. Signature Date Only applicants who sign and return this completed application will be considered for an interview.

5 Applicant Voluntary Survey The Green Hills AEA is committed to the principles of Equal Employment Opportunity and Affirmative Action. Please consider voluntarily providing the following information to assist us in determining the makeup of our applicant pool. This information will be used only for statistical purposes and will not be a part of the application process. Date Position applied for A. Are you 1. Male 2. Female B. What is your age group? or over C. What is the highest level of education you have attained? 1. Less than High School 2. High School Graduate/Equivalency 3. Completed college courses with no degree 4. Associate degree 5. BA, BS or similar undergraduate degree 6. MA, MS or similar graduate degree 7. Specialist or similar graduate degree 8. PhD, JD or similar professional degree D. Of what racial/ethnic group do you consider yourself a member? 1. White American/Caucasian: Origins in any of the original peoples of Europe, North Africa, or the Middle East. 2. African American/Black American: Origins in any of the black racial groups. 3. Asian/American: Origins in any of the original peoples of the Far East, Southeast Asia, Indian Subcontinent, or the Pacific Islands. 4. Native American: Origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. 5. Hispanic/American, Persons of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origin, regardless of race. 6. Biracial: Mixture of two or more of any of the above groups. 7. Other E. Do you consider yourself to be disabled? 1. No 2. Yes F. How did you learn about this job? 1. Agency employee. 2. Friend. 3. Referral Agency. Identify 4. Newspaper or periodical. Identify 5. AEA Website. 6. Other Website - Identify 7. Other Identify This is a Voluntary Survey Please return in separate envelope to: Green Hills AEA Human Resources Office P.O. Box 1109 Council Bluffs, IA Please let us know of suggested changes or comments regarding this form.

6 Green Hills Area Education Agency Notice to Prospective Employees Per Board Policy Green Hills Area Education Agency will conduct Background Checks of Prospective Hires. Green Hills Area Education Agency may obtain a copy of your consumer report, including a credit history report, for purposes of determining your eligibility for employment. In the event any adverse action were to be taken based in whole or in part on the consumer report, Green Hills Area Education Agency will first provide you with a copy of your consumer report and a full description of your rights under the Fair Credit Reporting Act, 15 U.S.C a et seq. Green Hills Area Education Agency will not automatically disqualify an applicant from employment by virtue of a criminal conviction. The Agency will examine the totality of circumstances to determine whether a criminal conviction disqualifies a candidate. In particular, the Agency will consider the nature of the crime, the date of the conviction, and the type of position sought by the applicant. Regardless, the Agency will not consider any applicant who has been convicted of a violent crime, including, without limitation, assault and battery, sexual assault, domestic abuse, or any similar conduct. Nor will the Agency consider any applicant convicted of a crime involving theft, embezzlement, or similar misappropriation of property for any position that would provide such applicant access to the property of the Agency, local education agencies, students, families, educators, or staff.

Last Name First Name Middle Name Social Security Number. Street Address City State and Zip Code. Yes No If not, state Date of Birth

Last Name First Name Middle Name Social Security Number. Street Address City State and Zip Code. Yes No If not, state Date of Birth Application for Employment Date Received: Orono Police Department Attn: Deputy Chief Chris Fischer Received By: 2730 Kelley Parkway Orono, MN 55356 952.249.4700 Please attach resume and letter of intent.