Form S 265 – Fill Out and Use This PDF

EMPLOYMENT RECORD

Begin with your most recent employment and work backwards. If you have had more than one position with the same employer, list each separately. Indicate, when applicable, whether the appointment was regular, provisional or substitute. ATTACH ADDITIONAL SHEETS IF NECESSARY.

NAME OF EMPLOYER AND WORK LOCATION	DATES EMPLOYED		POSITION TITLE		DUTIES AND RESPONSIBILITIES:
(FOR PHILADELPHIA TEACHING EXPERIENCE,				SALARY	YOU CAN BE CREDITED ONLY WITH THE EDUCATION
	FROM	TO	INDICATE FULL OR PART TIME
GIVE NAME OF SCHOOL)	MO/YR	MO/YR			AND EXPERIENCE SHOWN ON THIS APPLICATION
1. PRESENT

REASON FOR LEAVING:

2.

REASON FOR LEAVING:

3.

REASON FOR LEAVING:

CERTIFICATION AND RELEASE AUTHORIZATION

I certify that all of the statements made by me are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that any misrepresentation of information shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3) terminating my employment.

I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records, and to respond fully and completely to all questions that may be asked regarding my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and all claims that I might otherwise have against them with regard to statements made to the School District of Philadelphia. I further authorize these officials to investigate my background, now or in the future, to verify the information provided and release from liability all persons and/or entities supplying informa- tion regarding my background. However, I do not authorize the production of medical records or other information which would tend to actually identify a disability nor do I authorize inquiries which would include information related to any medical condition or medical history. Further, I do not waive any rights which I may have under state or federal law related to my right to challenge the disclosure of unlawful or inaccurate information, whether by the school district or by entities or persons providing such information to the school district, including any and all claims concerning allegations of employment discrimination because of race, color, sex, religion, national origin, ancestry, age or disability.

I do not authorize the School District of Philadelphia to check with my current employer.

Pennsylvania school districts shall not discriminate in their education programs, activities or employment practices based on race, color, national origin, sex, disability, age, religion, ancestry or any other legally protected classification. This policy is in accordance with state and federal laws, including Title VI of the Civil Right Act of 1964, Title IX of the Education Amendments of 1972, Sections 503 and 504 of the Rehabili- tation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990 and the Pennsylvania Human Relations Act. Information relative to special accommodation, grievance procedure, and the designated responsible official for compliance with Title VI, Title IX, and Section 504 may be obtained by contacting the school district.

ALL THREE SECTIONS: A, B, AND C MUST BE COMPLETED -- UNSIGNED APPLICATIONS WILL NOT BE PROCESSED.

C. I certify that all entries on this application are, to the best of my knowledge, true and complete.
I understand that any misstatement of material facts contained in this application may be cause for dismissal.	Signature:	Date: