FREMONT COUNTY SCHOOL DISTRICT #14. Classified Application PERSONAL DATA

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1 FREMONT COUNTY SCHOOL DISTRICT #14 Last Name, First, Middle Present Address City/State/Zip Permanent Address City/State/Zip When will you be available to work? Classified Application PERSONAL DATA Social Security Number Date Home Telephone Other Phone All classified staff employed by Fremont County School District #14 are employed as employees at-will and nothing contained herein nor anything in the policies of the District shall be construed to alter that employment status. Employees of Fremont County School District #14 are required to be familiar with and comply with the policies of Fremont County School District #14. A copy of the policy manual is contained in the individual school buildings, the central administration office and at the records department of the County Courthouse. Position Applied for: Are you a United States Citizen? Yes No If No, Alien Registration Number Employment History List your most recent position first. The Fremont County School District #14 does not discriminate on the basis of race, color, national origin, sex, age, or disability in admission or access to, or treatment or employment in, its educational programs or activities. Inquiries concerning Title II, Title VII, Title IX, may be referred to Dave Rushforth, Assistant Superintendent & Coordinator for the Office for Civil Rights, Inquiries concerning Section 504 may be referred to Pam Gambler, Section 504 Coordinator, or all inquiries may be mailed to the attention of the coordinator at Fremont County School District #14, 638 Blue Sky Highway, Ethete, Wyoming 82520

2 Skills Summarize special skills, qualifications and equipment used: Education Years Completed Diploma/Degree/ Certificate Other Education/ Training (example: CDL License) High School: GED College/University Graduate/Professional Major

3 Personal/Professional References List three references other than relatives: Name: Occupation: Length Of Acquaintance: PERSONAL DATA Are you aware of any reason (physical, mental, or otherwise) you would not be able to perform essential functions required of the position for which you are making application, with or without accommodations? YES NO Are you willing to come for an interview at your own expense? YES NO Conviction of a crime is not an automatic bar to employment. The district will consider the nature of the offense, the date of the offense, and the relationship between the offense and the position for which you are applying. Moral turpitude is an act of baseness, vileness, or depravity in the private and social duties which a person owes another member of society or society in general and which is contrary to the accepted rule of right and duty between persons, including, but not limited to theft, attempted theft, murder, rape, swindling, and indecency with a minor. Have you even been convicted of a felony or any offense involving moral turpitude or has any court received a plea of guilty of a plea of nolo contender from you? YES NO Have you ever been convicted of any felony or sentenced or received a deferred prosecution or probation for any charge including any crime relating to child abuse or neglect, or any crime relating to sexual abuse of a minor? YES NO Have you ever been discharged or forced to resign from any job? YES NO Pursuant to the provisions of W.S , any employee who is to be hired by the school board on or after July 1, 1966, who may have access to minors, is required to submit to fingerprinting and to provide such other information as is necessary to acquire a national criminal history background check. Employees who are required to be certified by the Professional Teaching Standards Board may have already provided the necessary fingerprinting information to permit the Professional Teaching Standards Board to have conducted a criminal background check. Have you, within the past year, provided the necessary information to the Professional Teaching Standards Board to allow them to conduct a criminal background check or had a criminal background check performed by another agency? YES NO If YES please provide a copy to the School District with your application. If NO, you will need to have a background check completed and provide a copy of the results to the school district BEFORE you can be considered for the job. ALL applicants MUST have a completed background check. Even if you have had a separate criminal background check done, the school district may, at its option, conduct a separate criminal background check. In addition, if you are not required to be certified by the Professional Teaching Standards board or if you have not had a criminal background check conducted within the past year, the school district will need your consent to provide the appropriate fingerprint and other information necessary for the district to conduct a criminal background check. Will you give the school district your consent to conduct this criminal background check? YES NO Are you prevented from being lawfully employed in this country because of VISA or Immigration status? YES NO

4 Proof of citizenship or immigration status will be required upon employment. FREMONT COUNTY SCHOOL DISTRICT #14 Please completed the following questions in the space provided in your own handwriting. 1. Why do you want to work for this School District? 2. If employed by Fremont County School District #14, how would the District benefit?

5 Authorization I authorize any school district to which this application is submitted to obtain information about my criminal records. I authorize all governmental agencies to provide information about my criminal records to the school district. I verify that all information on this employment application is true and complete. I understand that any misrepresentation, falsification, or omission on this application or on other documents submitted to the school district will be sufficient cause for this application not to be considered by the school district or for discharge if I have been employed. I authorize any Wyoming school district for which I have completed an employment application to check my references, to obtain information from my prior employers and educational institutions, and to take other actions to investigate any information provided in my employment application, and to obtain information relevant to evaluating my qualifications and fitness for a teaching position. I authorize the release of any and all information n or records maintained by the Wyoming Department of Family Services. I authorize my listed references, past work employers and educational institutions, and anyone else who has information about my work history, education qualification or fitness, to provide such information to any school district for which I have completed an employment application. I release the school district and all persons providing information to the school district from any liability whatsoever for obtaining and providing that information regardless of the results. Upon occasion, school districts are asked by other educational institutions, such as other districts, to provide names of candidates for areas in which they have vacancies. Would you be willing to have your application information shared with these other institutions? YES NO Signature Date This application will be kept only for one (1) year. However, each time a new position opens up which you desire to be considered for, you must notify the District of your intent to reactivate your application. If more than one year has passed, please submit a new application.