Central Dauphin School District Employment Application 600 Rutherford Road Harrisburg, PA 17109 (717) 545-4703 (717) 214-1845 FAX Applicants are requested to complete this form in their own handwriting. Return the completed application to the Director of Human Resources. Check the appropriate boxes: CLERICAL 12 Month 210 Days 200 Days Substitute BUILDINGS AND GROUNDS Full-time Mechanical Custodial Substitute (custodial only) CAFETERIA Full-time and/or part-time Substitute HEALTH ASSISTANT (191 days) LPN TRANSPORTATION Bus/Van Driver Mechanic PARAPROFESSIONAL AIDE (full-time and/or part-time) (191 days) PARAPROFESSIONAL SUBSTITUTE NONINSTRUCTIONAL AIDE (part-time only) Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or disability which does not prevent the applicant from being capable of performing the essential functions of a position, with or without reasonable accommodation. An equal opportunity employer. PERSONAL Name/Mr. Mrs. Miss Last First Middle Present Street Home Phone City State Zip Business Phone Were you employed by the School District before? If yes, give dates and position held Are you over the age of 18? Will any outside activity interfere with your job performance? - 1-4-05-100
EDUCATION Course of Years Completed Did You Degree School Name and of School Study (circle) Graduate? or Diploma Elementary/ Middle 4 5 6 7 8 School High School 9 10 11 12 College 1 2 3 4 Other 1 2 3 4 Honors received: EMPLOYMENT EXPERIENCE List below all present and past employment. Begin with your present or most recent employer. May we contact this employer? May we contact this employer? May we contact this employer? Additional employers may be listed on another sheet. - 2 -
PERSONAL REFERENCES List three references who are not related to you. Name Position Phone Number 1. 2. 3. PREFERENCE OF LOCATION FOR EMPLOYMENT (Excluding Transportation) Check all locations where you will accept employment. Central Dauphin Sr. CD East Sr. CD Middle CD East Middle Linglestown Middle Swatara Middle Chambers Hill Lawnton Linglestown Elem. Middle Paxton Mt. View rth Side Paxtang Paxtonia E.H. Phillips Rutherford South Side Tri-Community West Hanover Administration Bldg. COMPLETE THIS SECTION FOR CLERICAL OR NONINSTRUCTIONAL AIDE ONLY Check those operations you are capable of performing. Typing: words per minute Dictation equipment Filing Receptionist Bookkeeping Payroll Calculator Library experience operator Personal Computer Other, please identify: COMPLETE THIS SECTION FOR TRANSPORTATION EMPLOYMENT (Including Bus Mechanics) 1. Pennsylvania Operator s License Number 2. (a) Do you have a Pennsylvania School Bus License? (b) Do you have a Pennsylvania Commercial Driver s License? If yes, what class? What restriction? 3. Have you been arrested for any moving traffic violation in the past five years? If yes, please list: 4. Have you been involved in any traffic accidents in the past five years? If yes, please list: 5. Family Physician 6. Did you drive a commercial vehicle for any prior employer? If yes, please identify each employer for whom you have driven a commercial vehicle. 7. During the previous two years, have you had an alcohol test showing a concentration of 0.04 or greater or a positive controlled substances test or have you refused to be tested? If yes, identify: (a) the employer for whom you were employed: - 3 -
Also identify: (b) the circumstances surrounding the testing or refusal to be tested: ALL APPLICANTS (c) any substance abuse professional who may have evaluated you: The Commonwealth of Pennsylvania, Bureau of Traffic Safety, has established certain criteria for health qualifications as relating to school bus drivers. You must be able to meet this criteria before you can be employed as a school bus driver. 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 ever been convicted of a felony or any offense involving moral turpitude? Have you ever been convicted of a felony or any offense involving moral turpitude and received probation? Has any court ever received a plea of guilty or a plea of nolo contendre from you for any offense involving moral turpitude, deferred further proceedings without entering a finding of guilty and placed you on probation? 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. Why do you desire to leave your present position, or why did you leave you last position? Have you ever been involuntarily terminated or asked to resign from the employment of another school district? If yes, please give the name of the district, the date and the reason for the termination or request for resignation: Are you capable of performing the essential functions of the position for which you are applying, with or without reasonable accommodations, and do you possess all legal qualifications for the position? If no, please explain: AGREEMENT I hereby certify that the above information to the best of my knowledge is true, accurate and complete. Any misrepresentation or willful omissions of facts shall be sufficient cause for disqualification of this application or termination of employment. Furthermore, it is understood that this application and records become the property of the District which reserves the right to accept or reject it. I further agree to observe all rules, regulations and policies of the District now in force and effect or as they may change during my employment, if I am employed by the Central Dauphin School District. Signature of applicant Return this application to: Director of Human Resources, Central Dauphin School District, 600 Rutherford Road, Harrisburg, PA 17109-4 - I hereby authorize the Central Dauphin School District to conduct work history, personal reference or police record inquiries to determine by acceptability for employment. Signature of applicant Date Date
HUMAN RESOURCES DEPARTMENT USE ONLY Interview Interviewer Date Time Position Comments Reference Check Person Making Contact Date Time Position Comments Date of Employment: Job Classification: Salary/Hourly Rate: Department: - 5 -