NORTH WASCO COUNTY SCHOOL DISTRICT 21 HUMAN RESOURCES DEPARTMENT 3632 West 10 th Street The Dalles, Oregon 97058 (541) 506-3420 or online at www.nwasco.k12.or.us of Application: Position applied for: Contact Phone Number Name: Last First Middle Email address Address: Have you been employed by North Wasco County SD21 before? Yes No Are you a member of the Oregon State Retirement System? Yes No If hired you will be required to submit identification in accordance with Immigration and Naturalization Service requirements. North Wasco County School District No. 21 is a Drug Free and Tobacco Free Worksite. All offers of employment are contingent upon pre-employment drug testing results. PHYSICAL INFORMATION Some of our jobs have specific physical or mental requirements or limitations. If you are applying for such a position, our personnel staff will ask you about physical limitations or disabilities that would impact your job performance. Such questions will be related only to your potential performance on the job for which you are applying. No applicant will be disqualified because of a physical or mental impairment unless as a result the applicant is unable to perform the essential functions of the position with or without reasonable accommodation. Please review the job duties on the attached job description. Are you able to perform all of the requirements of this job? Yes No If not, please identify those duties you would not be able to perform or would need accommodation to perform. CRIMINAL CONVICTION Some jobs in North Wasco County School District may not be held by persons convicted of certain crimes listed in ORS 342.143 or in OAR 581-22-716 (9) or who have made a false statement about the conviction of a crime. If you are applying for such a position, our personnel staff will ask you if you have been convicted of a crime that would disqualify you for the particular job you are interested in. The existence of a criminal record, per se, is not an automatic bar to employment with this school district. Complete all portions of the application. Incomplete or unsigned applications will not be accepted. Deliver, Fax or Mail this Application to: North Wasco County School District #21 3632 West 10 th Street The Dalles, Oregon 97058 Applications may be found on the District s Website: www.nwasco.k12.or.us
EDUCATIONAL TRAINING / PERSONAL REFERENCES Classified Personnel Application EDUCATIONAL TRAINING Name and Location of School Circle Years Completed Degree, Diploma, or Certification High School 9 10 11 12 College or University 1 2 3 4 Other 1 2 3 4 Describe specialized training, apprenticeships, skills, and extra-curricular activities. Attach additional sheets if necessary. PERSONAL REFERENCES (Not Former Employers or Relatives) Name and Address Phone Position Name and Address Phone Position Name and Address Phone Position Name and Address Phone Position Name and Address Phone Position
EMPLOYMENT HISTORY Classified Personnel Application Start with your present or most recent position and list all the positions you have held in chronological order. Include military service and volunteer activities. Describe each job separately, emphasizing your specific tasks and supervisory, technical or other responsibilities. Give special attention relating to the job for which you are applying. Explain breaks in work experience. Attach additional sheets if necessary. EMPLOYMENT HISTORY Name and Address of Employer Job Title Work performed: Name of Supervisor Employer's Phone ( ) s Employed Month & Year from to Annual Salary $ Reason for Leaving Name and Address of Employer Job Title Work performed: Name of Supervisor OK to contact current employer? Employer's Phone ( ) s Employed Month & Year from to Annual Salary $ Reason for Leaving Name and Address of Employer Job Title Work performed: Name of Supervisor Employer's Phone ( ) s Employed Month & Year from to Annual Salary $ Reason for Leaving Name and Address of Employer Job Title Work performed: Name of Supervisor Employer's Phone ( ) s Employed Month & Year from to Annual Salary $ Reason for Leaving
North Wasco County School District 21 SEXUAL MISCONDUCT DISCLOSURE INFORMATION The Oregon Legislature has determined that additional safeguards are necessary in the hiring of school district employees to ensure the safety of Oregon s school children. Your last three education employers will be notified and required to state any substantiated report of child abuse or sexual conduct related to the applicant s employment with the education provider. *Note: Please include your work history even if you did not work for an education provider. For each current or former education providers listed above, please fill out and sign the Sexual Misconduct Disclosure Release form attached to this application (complete the top section of the form only). Additional Sexual Misconduct Disclosure Release forms may be found with the Human Resources Department. The facts set forth on this application for employment are true and complete to the best of my knowledge. I understand that if employed, false statements on this application shall be considered sufficient cause for dismissal. I hereby grant the district or its agent permission to check civil or criminal records to verify any statements on this application. Applicant Signature Written Statement by applicant: (The following questions must be answered completely pursuant to ORS 339.374 & 339.378) 1. Have you EVER been the subject of a substantiated report of child abuse or sexual conduct (involving a K-12 student or minor child)? No Yes If yes please explain. 2. Are you currently the subject of an ongoing investigation related to a report of suspected child abuse or sexual conduct (involving a K-12 student or minor child)? No Yes If yes please explain. 3. Have you listed ALL current and former employers who are education providers in the Experience section above? No Yes (For additional education providers, please list on the back of this form or attach a separate sheet.) Applicant Signature
I N D I V I D U A L R E S P O N S E S Classified Personnel Application Please write your responses to the next two questions. 1. List other experiences (volunteer or professional) relevant to the position for which you are applying. 2. Please write a brief paragraph explaining how you feel you can make a contribution to the students of North Wasco County School District. Signature By my signature above, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers my application may be rejected, my name removed from consideration, or my employment with the District terminated. If application is for a position that is posted, we will hold application for six months, otherwise, will hold for three months. All application materials submitted become the property of North Wasco County School District No. 21.
AUTHORIZATION TO CHECK WORK HISTORY AND RELEASE OF PRIOR EMPLOYERS Classified Personnel Application NORTH WASCO COUNTY SCHOOL DISTRICT #21 I authorize North Wasco County School District #21 to check my references and to investigate any information provided in my application for employment. I further authorize my past employers or anyone with information about my work history, education or qualifications to provide such information to North Wasco County School District #21 in response to their inquiry. I agree to hold harmless from any liability (suit, claim or other action) anyone supplying such information to NORTH WASCO COUNTY SCHOOL DISTRICT NO 21. I further authorize North Wasco County School District #21 to discuss the results of any investigation with all of their employees who are involved in the hiring process. Print your name: Signature North Wasco County School District #21 has an Affirmative Action Policy
NON-DISCRIMINATION STATEMENT North Wasco County School District 21 NON-DISCRIMINATION STATEMENT EQUAL OPPORTUNITY North Wasco County School District #21 announces, in compliance with all applicable federal and state laws, that it will continue to eliminate discrimination in its education programs and activities. The Policy of nondiscrimination also applies to the employment practices of the District. North Wasco County School District #21 is an equal opportunity educator and employer. It is the policy of the North Wasco County School District Board of Education and School District that there will be no discrimination or harassment on the grounds of race, color, sex, sexual orientation, marital status, religion, national origin, age or disability in any educational programs, activities or employment. Persons having questions about (equal opportunity and non-discrimination) should contact the Superintendent at North Wasco County School District Office, (541) 506-3420 or TDD 1-800-735-2900. The Superintendent has been appointed Compliance Officer. Any person seeking more information on or who has a grievance may contact the Superintendent at the District Administration Office or by telephone (541) 506-3420 or may contact directly the Region Ten Civil Rights Office at 1321 Second Avenue, Seattle, Washington 98101, (206) 442-1930 Reasonable accommodations for the application interview process will be provided upon request and as required in accordance with the Americans with Disabilities Act of 1999. Disabled persons may contact North Wasco County School District #21, Human Resources Office at (541)506-3420 for additional information and assistance. DRUG-FREE WORKPLACE North Wasco County School District #21 is committed to maintaining a drug-free workplace and strictly complies with the Drug-Free Workplace Act of 1988 and the Drug-Free Schools and Communities Act amendments of 1989. North Wasco County School District No. 21 is a Drug Free and Tobacco Free Worksite. All offers of employment are contingent upon pre-employment drug testing results.
CRIMINAL HISTORY RECORDS CHECK/FINGERPRINTING Classified Personnel Application NORTH WASCO COUNTY SCHOOL DISTRICT 21 Consent Form Criminal History Records Check and/or Fingerprinting Check Individuals will be required to complete the following as part of the approved process for volunteer service or employment as an employee or independent contractor. 1. I understand that criminal history record checks and/or fingerprinting are required by law and/or Board policy. Employment shall be offered prior to fingerprint collection. Upon notification by the Superintendent of Public Instruction or designee or State Board of Education that an individual has been convicted or has made a false statement as to conviction of any crimes prohibiting employment or contract status with the District, the Superintendent shall terminate that employment or contract status immediately. 2. I understand that an individual so terminated may appeal action taken by the District as a result of such checks in accordance with procedures established by law or Board policy. Applicable appeal rights will be provided by the District upon such termination from District employment or contract status. 3. Any fees associated with criminal history records checks and fingerprinting, not to exceed actual costs, shall be responsibility of the individual. 4. Should I refuse to consent to criminal history checks or refuse to be fingerprinted, I shall be terminated from employment or contract status by the Superintendent immediately. I understand that individuals who have successfully completed any Oregon and FBI criminal history records check by a previous employer and have not since resided outside Oregon may be exempt from this requirement. It is the responsibility of the individual to inform the District of existence of such records. Federal law requires all new employees have a criminal history check and be fingerprinted. There is a charge for the fingerprinting. A $15.00 fee is charged for fingerprinting and a $59.00 fee is due for the FBI Criminal Check on the fingerprints. The $15.00 is due at the time of fingerprinting and the $59.00 can be paid at that time or can be deducted from your first paycheck. Fingerprinting will not be required until the applicant has been offered a position. Applicant Signature
Oregon Department of Education Office of Finance and Administration Public Service Building Pupil Transportation and Fingerprinting 255 Capitol Street NE 503-947-5600 Salem, Oregon 97310 CRIMINAL HISTORY VERIFICATION OF APPLICANTS Please type or print clearly. As Appears on License Name: of Birth: Sex: (Last Name) (First Name) (Middle Name) MM/DD/YY List Other Names Previously Used: (includes Maiden Name) Social Security No.: Driver License/Identification Card No.: Providing your social security number on this form is voluntary. If you choose not to disclose the social security number, this will not be a basis for denial of employment or any rights, services or benefits to which you are otherwise entitled. If you do provide the number the Oregon State Police will use it as an additional identifier to search for any criminal record you may have. Your social security number will be used as stated above. State and federal laws protect the privacy of your records. Mailing Address: Full Street Address/Post Office Box City: State: Zip + 4: A. Have you EVER been convicted of a sex-related crime? [ ] Yes [ ] No If yes, was the conviction in Oregon or another state? (Please specify if another state.) State: If yes, did the crime involve force or minors? [ ] Yes [ ] No B. Have you EVER been convicted of a crime involving violence or threat of violence? [ ] Yes [ ] No If yes, was the conviction in Oregon or another state? (Please specify if another state.) State: C. Have you EVER been convicted of a crime involving criminal activity in drugs or alcoholic beverages? [ ] Yes [ ] No If yes, was the conviction in Oregon or another state? (Please specify if another state.) State: D. Have you EVER been convicted of any other crime except a minor traffic violation?(includes Traffic Crimes) [ ] Yes [ ] No E. Have you been arrested within the last three years for a crime for which there has not yet been an acquittal or dismissal? [ ] Yes [ ] No ** IF YES IS MARKED ABOVE, PROVIDE WRITTEN EXPLANATION ** Advisory: A check of the applicant's criminal history will be made by the Oregon Department of Education to verify the responses to the preceding questions. I hereby grant to the Oregon Department of Education permission to check civil or criminal records to verify any statement made on this form. Regardless of whether the applicant grants consent, the Oregon Department of Education will conduct a criminal offender record check of applicants for the position of school bus driver, volunteer, or other prospective school employees working with or around children. The applicant is entitled to review his/her criminal history for inaccurate or incomplete information. Discrimination by an employer on the basis of arrest records alone may violate federal civil rights law. The applicant may obtain further information concerning the applicant's rights by contacting the Bureau of Labor and Industries, Civil Rights Division, State Office Building, Suite 1070, Portland, Oregon 97232, telephone (503) 731-4075. I acknowledge reading and the receipt of this notice. Applicant's Signature: Form 581-2282-M (Rev. 9/09) : This Form may be reproduced locally without change.
North Wasco County School District 21 3632 West 10 th Street The Dalles, Oregon 97058 SEXUAL MISCONDUCT DISCLOSURE RELEASE Dear Former Employer, : The named applicant is under consideration for a position in our District. The Oregon Legislature has determined that additional safeguards are necessary in the hiring of school district employees to ensure the safety of Oregon s school children. The individual whose name appears below has indicated they have had previous employment with your organization. As a former employer, we request you provide the information requested on this form within twenty (20) business days pursuant of Oregon Revised Statutes 339.374 and 339.378. Thank you for your assistance. If you have any questions, please contact our Human Resources Department at (541) 506-3420. Candy Armstrong - Superintendent Former Employer Information School District / ESD/Provider: Address: City, State, Zip Former Employee Information Last Name: First name: Middle Initial: SSN# Position held: s Employed: I authorize you to release to North Wasco County School District 21, all information required to be released by Oregon Revised Statute 339.378 and related to any substantiated reports of child abuse, sexual conduct or crimes listed in Oregon Revised Statute 342.143. I release the above employer and employees acting on behalf of the employer from any liability for providing information described in this document. Applicant Signature This section to be completed by previous employer pursuant to ORS 339.374 & 339.378: s former employee was employed by you: From to. The employee was was not the subject of a substantiated report of child abuse or sexual conduct related to the applicant s employment with the education provider. (s) of Substantiated Report: Please attach the definition of child abuse and sexual conduct used by your District when determining a substantiated report and standards used by the education provider to determine whether any reports were substantiated. Former Employer Representative Signature Printed Name Title Oregon Definition of Sexual Conduct: Sexual Conduct means any verbal or physical conduct by a school employee that: 1. Is sexual in nature; 2. Is directed toward a kindergarten through grade 12 student; 3. Has the effect of unreasonable interfering with a student s educational performance; and 4. Creates an intimidating, hostile or offensive educational environment. Please return completed information to North Wasco County School District 21 3632 West 10 th Street, The Dalles, Oregon 97058 (Fax) 541-298-6018 D21 Staff Only: Received: Reviewed by:
North Wasco County School District 21 3632 West 10 th Street The Dalles, Oregon 97058 SEXUAL MISCONDUCT DISCLOSURE RELEASE Dear Former Employer, : The named applicant is under consideration for a position in our District. The Oregon Legislature has determined that additional safeguards are necessary in the hiring of school district employees to ensure the safety of Oregon s school children. The individual whose name appears below has indicated they have had previous employment with your organization. As a former employer, we request you provide the information requested on this form within twenty (20) business days pursuant of Oregon Revised Statutes 339.374 and 339.378. Thank you for your assistance. If you have any questions, please contact our Human Resources Department at (541) 506-3420. Candy Armstrong - Superintendent Former Employer Information School District / ESD/Provider: Address: City, State, Zip Former Employee Information Last Name: First name: Middle Initial: SSN# Position held: s Employed: I authorize you to release to North Wasco County School District 21, all information required to be released by Oregon Revised Statute 339.378 and related to any substantiated reports of child abuse, sexual conduct or crimes listed in Oregon Revised Statute 342.143. I release the above employer and employees acting on behalf of the employer from any liability for providing information described in this document. Applicant Signature This section to be completed by previous employer pursuant to ORS 339.374 & 339.378: s former employee was employed by you: From to. The employee was was not the subject of a substantiated report of child abuse or sexual conduct related to the applicant s employment with the education provider. (s) of Substantiated Report: Please attach the definition of child abuse and sexual conduct used by your District when determining a substantiated report and standards used by the education provider to determine whether any reports were substantiated. Former Employer Representative Signature Printed Name Title Oregon Definition of Sexual Conduct: Sexual Conduct means any verbal or physical conduct by a school employee that: 1. Is sexual in nature; 2. Is directed toward a kindergarten through grade 12 student; 3. Has the effect of unreasonable interfering with a student s educational performance; and 4. Creates an intimidating, hostile or offensive educational environment. Please return completed information to North Wasco County School District 21 3632 West 10 th Street, The Dalles, Oregon 97058 (Fax) 541-298-6018 D21 Staff Only: Received: Reviewed by:
North Wasco County School District 21 3632 West 10 th Street The Dalles, Oregon 97058 SEXUAL MISCONDUCT DISCLOSURE RELEASE Dear Former Employer, : The named applicant is under consideration for a position in our District. The Oregon Legislature has determined that additional safeguards are necessary in the hiring of school district employees to ensure the safety of Oregon s school children. The individual whose name appears below has indicated they have had previous employment with your organization. As a former employer, we request you provide the information requested on this form within twenty (20) business days pursuant of Oregon Revised Statutes 339.374 and 339.378. Thank you for your assistance. If you have any questions, please contact our Human Resources Department at (541) 506-3420. Candy Armstrong - Superintendent Former Employer Information School District / ESD/Provider: Address: City, State, Zip Former Employee Information Last Name: First name: Middle Initial: SSN# Position held: s Employed: I authorize you to release to North Wasco County School District 21, all information required to be released by Oregon Revised Statute 339.378 and related to any substantiated reports of child abuse, sexual conduct or crimes listed in Oregon Revised Statute 342.143. I release the above employer and employees acting on behalf of the employer from any liability for providing information described in this document. Applicant Signature This section to be completed by previous employer pursuant to ORS 339.374 & 339.378: s former employee was employed by you: From to. The employee was was not the subject of a substantiated report of child abuse or sexual conduct related to the applicant s employment with the education provider. (s) of Substantiated Report: Please attach the definition of child abuse and sexual conduct used by your District when determining a substantiated report and standards used by the education provider to determine whether any reports were substantiated. Former Employer Representative Signature Printed Name Title Oregon Definition of Sexual Conduct: Sexual Conduct means any verbal or physical conduct by a school employee that: 1. Is sexual in nature; 2. Is directed toward a kindergarten through grade 12 student; 3. Has the effect of unreasonable interfering with a student s educational performance; and 4. Creates an intimidating, hostile or offensive educational environment. Please return completed information to North Wasco County School District 21 3632 West 10 th Street, The Dalles, Oregon 97058 (Fax) 541-298-6018 D21 Staff Only: Received: Reviewed by:
NORTH WASCO COUNTY SCHOOL DISTRICT NO 21 AFFIRMATIVE ACTION INFORMATION (OPTIONAL) STATEMENT OF CONFIDENTIALITY THIS FORM IS MAINTAINED SEPARATELY FROM APPLICATION MATERIALS AND IS USED FOR STATISTICAL RECORD KEEPING PURPOSES ONLY. ALL INFORMATION IS CONSIDERED CONFIDENTIAL. This information is requested solely to monitor equal employment opportunity and is for statistical purposes only. Your completion of this section is voluntary, and refusal to give this information will not affect your opportunity for employment with our district. Thank you for your cooperation. DATE: POSITION: A. RACE/CULTURAL GROUP: AFRICAN AMERICAN B. SEX: ASIAN/PACIFIC ISLANDER HISPANIC NATIVE AMERICAN/ALASKAN NATIVE WHITE FEMALE MALE C. DATE OF BIRTH: D. HOW DID YOU LEARN OF THIS OPENING? Newspaper Employment Office Walk-in District Website Other EQUAL OPPORTUNITY EDUCATOR & EMPLOYER We consider all applicants for positions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, marital status, age, mental or physical disabilities, veteran/reserve/national guard, or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate based on any unlawful criteria.