-  Application

North Bolivar Consolidated School District	

For Employment

201 Greene Street
Mound Bayou, Mississippi   38762

(PLEASE PRINT)

Position(s) Applied 	Date of Application	
Area of Certification   	 Are You Certified? 	Yes	No 	Certification  Number _____________________________	

Last Name 	First Name 	Middle Name	
Address 	Number 	Street	City 	State	Zip Code	
Telephone Number(s)	Social Security Number
I	I	

     Have you ever filed an application with us before?                                           	_____ Yes     _____ No

                                                                                                                                	 If Yes, give date _______

    Have you ever been employed with us before?                                                 	_____  Yes     _____ No

                                                                                                                                 	If Yes, give date _______

    Are you currently employed? 							_____ Yes     _____ No

    May we contact your present employer?						_____ Yes     _____ No

    Are you prevented from lawfully becoming employed in this country
    because of Visa or immigration status?						_____ Yes     _____ No
    Proof of citizenship or immigration status will be required upon employment.

    On what date would you be available for work?   					_____________________
                                                                                                                                    Month             Day               Year

   Have you been convicted of a felony?						_____ Yes     _____ No
  Conviction will not necessarily disqualify an applicant from employment. 

   If Yes, please explain:  ___________________________________________________________________

   ______________________________________________________________________________________

  _______________________________________________________________________________________

	

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.
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Employment Experience

Start  with your present or last job. Include any job-related military service assignments and volunteer  activities. You may exclude organizations which indicate race,  color, religion,  gender, national origin, disabilities or other protected status.

1.	_________________________________________________________________________________

	_________________________________________________________________________________

	_________________________________________________________________________________

2.	_________________________________________________________________________________

	_________________________________________________________________________________

	_________________________________________________________________________________

3.	_________________________________________________________________________________

	_________________________________________________________________________________

	_________________________________________________________________________________

	_________________________________________________________________________________
If you need additional space, please continue on a separate sheet of paper.

List professional, trade, business or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:

_______________________________________________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

    References
      1. _______________________________________________________________(____)_________________
(Name) 	       (Phone#)

(Address)

        2. . ________________________________________________________________________________________(______)________________________
(Name) 	       (Phone#)

(Address)

        3. _______________________________________________________________________________________(______)________________________
                                                                                       (Name) 	       (Phone#)

(Address)

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Education

Institution	Name/Address	Course of Study	Years Completed	Diploma/Degree	
Elementary
School					
High
 School					
Undergraduate 
College					
Graduate 
Professional					
Other
(Specify)					

Describe your philosophy of education:

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship
with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment rela­ tionship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s)
may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

                  Signature of Applicant 	                 Date

FOR PERSONNEL DEPARTMENT USE ONLY	
Arrange Interview                    _____ Yes     _____ No

Remarks ________________________________________________________________________________

                ________________________________________________________________________________

                ________________________________________________________________________________
                                                                                                                INTERVIEWER                          DATE

Employed                                 ______ Yes     _____ No      Date of Employment ______________________

Job Title _______________________________     Salary __________  Department ___________________

                                                     By ___________________________________________________________
                                                                                          NAME AND TITLE                                                DATE

Position(s) Applied For is Open:     _____ Yes     _____ No

Position(s) Considered For:     _______________________________________________________________
 
                                                    _______________________________________________________________

Date __________________________________________________ 

	

NOTES ____________________________________________________________________________________

___________________________________________________________________________________________
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