Levelland Isd Form – Fill Out and Use This PDF

__________________________________

Signature of Applicant or Employee

____/____/____

Date

______________________________________

Agency Name (Please Print)

______________________________________

Agency Representative Name

______________________________________

Signature of Agency Representative

____/____/____

Date

Please:

Check and Initial each Applicable Space

CCH Report Printed:
YES_____NO_____	_____Initial
Purpose of CCH:__________________________
Hired_____Not Hired_____	_____Initial
Date Printed:___/___/___	_____Initial
Destroyed Date:___/___/___	_____Initial
Retain in your files

Personal Data

Position Data

Education & Training

Date of Application:__________________	Social Security Number: ___________________
Last Name: ________________________	First Name: _____________________________

Current Address: ____________________ City/St/Zip: _____________________________

Work Phone: _______________________ Home Phone: ___________________________

Email Address: ______________________________________________________________

Other address where you may be reached: _________________________________________

Other name that might appear on your records: ______________________________________

List the position(s) you are applying for:	Substitute Teacher
	Substitute Teacher Aide (Persons with less than 15
	college hours may substitute for teachers aide only)
Date you can begin work:_________________________
Have you been employed by Levelland I.S.D. in the past?		YES	NO

If you answered yes, provide dates of employment _________________________________

Check the highest level of education attained:	1	2	3	4	5	6	7	8	9	10	11	12

Not a high school graduate (choose last grade completed)

	High School Graduate		GED
	Two or more years of college		Less than two years of college
	Other training or education		Bachelor s Degree
	Licenses and certificates held		Masters Degree
	Name and location of schools	Course of study and		Diploma, Degree,	Year Graduated
	attended	Major/Minor		Certificate, or License	(College Only)
				held

Work Experience

An Equal Opportunity Employer

Please provide a complete list of all positions you have held in the past 10 years. List the most recent first. Attach additional sheets if necessary. Attach resume if available.

Employer and Location

Position/Title

Date Employed

Reason for Leaving

General Information

References

Employment Application for Substitute Teachers/Substitute Teacher Aides

An Equal Opportunity Employer

Do you have a relative who serves on the Levelland I.S.D. Board of Education? YES NO If yes, please provide the relative s name and relationship: _______________________________

Are you physically and mentally able to perform the job(s) for which you are applying?

YES NO

If no, please explain.

__________________________________________________________________________________

__________________________________________________________________________________

Have you been asked to resign or been discharged from any position? YES NO

If yes, explain. _________________________________________________________________

_____________________________________________________________________________

Have you ever been convicted of, pled guilty to, or no contest (nolo contendre) to, or received probation, suspension, or deferred adjudication for a felony or offense involving moral turpitude (including, but not limited to, theft, rape, murder, swindling, and indecency with a minor)?

YES NO

If YES, please state where, when, and the nature of the offense:

__________________________________________________________________________________

__________________________________________________________________________________

(A felony is not an automatic bar to employment. The district will consider the nature, date, and relationship between the offense and the position for which you are applying.)

Please list references the district can contact regarding your work history. Include all managers and supervisors who evaluated or supervised your performance at your last two employments.

	Full Name of	School District	Mailing Address	Position/Title	Area Code &
	Reference	Firm Name			Phone Number

Citizenship

Verification

Employment Application for Substitute Teachers/Substitute Teacher Aides

An Equal Opportunity Employer

Are you a U.S. citizen, U.S. national, lawful permanent resident, lawful temporary resident, or

refugee? YES NO

Upon hiring, I agree to complete the I-9 form provided by the District.

____________________	_________________________________
Date	Signature

I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application or dismissal from subsequent employment.

I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all such parties from liability for any damage that may result from furnishing the same to you.

I understand that the district is authorized by Texas Educational Code §22.083 to obtain criminal history record information on applicants the district intends to employ.

__________________________________	________________
Signature	Date

This application becomes the property of the district. The district reserves the right to accept or reject it. This application shall be considered active for 12 months. If you have not received a response during this time period, you may reapply or reactivate your application.

Criminal History Record Information Addendum

Employment Application for Substitute Teachers/Substitute Teacher Aides

An Equal Opportunity Employer

Confidential

The Levelland Independent School District is required by state law to obtain criminal history record

information on applicants being considered for employment with the district (Texas Education Code

§21.917). The information requested below is necessary to obtain criminal history record information.

Full Name (Print): ________________________________________________________________

Social Security Number: __________________________________________________________

Date of Birth: ___________________________________________________________________

Drivers License Number: __________________________________________________________

I give my consent to obtain my criminal history record.

I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for employment, but will be used solely for the purpose of obtaining criminal history record information. I also understand that this form can/will be used on an annual basis.

Signature: _____________________________________

Date: ____________________

This form will be removed from the application and filed separately.