2525 Lake Helena Drive East Helena, M



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Prickly PEAR COOPERATIVE

2525 Lake Helena Drive

East Helena, MT. 59635

Optimizing Resources--Unlocking Potential”

 
EMPLOYMENT APPLICATION - CERTIFIED PERSONNEL

FOR COOPERATIVE USE ONLY


Date of Application

Application Materials Received Autobiography

Transcripts

Placement File

Certificate

Ethnic Status

Interviewed by

Rejection Letter

Elected Accepted

Position School

Creditable Years. of Experience

Degree + +

Base Credits Step

The information contained on this form is sought in

good faith. It will not be used in any way to discriminate

against any applicant for employment in violation of

state or federal law. Autobiography






Equal Opportunity Employment

It is the policy of the Prickly Pear Cooperative to prohibit

discrimination against any individual for reasons of race, creed,

religion, color, national origin, age, marital status, sex, political

affiliation, disability, and socioeconomic conditions. The district

shall follow state statutes with respect to discrimination in

employment (49-2-303,307, and 310; 49-3-210 and 205, MCA).
IMPORTANT: Please type or print in ink. You must sign and date in ink each application you submit. INCOMPLETE OR UNSIGNED applications will not be considered.
PLEASE READ THE JOB VACANCY ANNOUNCEMENT CAREFULLY TO FIND:

(a) what attachments must be submitted; (b) where to submit your application; (c) the required special qualifications or licenses; and (d) the closing date for receipt of applications. An application tailored to the position is to your advantage.


Name:

Last First Middle Initial

Present Address:



Street/P.O. Box City State Zip
Telephone: Home: Work:

Email:


Social Security Number:

For what position are you applying:



Date that you can begin work: Date of this Application:

Are you currently under contract? Yes No Dates of contract:




To the Applicant: After completing this form, please return it to Vaughn Kauffman, Director,

2525 Lake Helena Drive, East Helena, Montana 59635,

email to sdempsey@ehps.k12.mt.us or fax to 406/227-8039

Applications will be active until November 1 following the date of receipt. To be considered for a subsequent school year, the applicant must fill out a renewal form which may be obtained from the Prickly Pear Cooperative Office.


High School Attended: Graduation Date:
City State Zip

Qtr. Hours

Name and Location of School Degree & Date Received Earned Major Minor











































Indicate all degrees and additional credits earned for salary schedule placement consideration. (Note: If your work is listed in “Semester Hours”, make note of it.)

STUDENT TEACHING/PRACTICUM EXPERIENCE: (Beginning Teachers Only):
Name and Location of School Dates Grade Level Subjects Taught













TEACHING/PROFESSIONAL EXPERIENCE: (Do not list substitute teaching, instructional aide work, or student teaching. List only contracted teaching experience. Begin with most recent.):

Inclusive Grades & Subjects Extracurricular

Name and Location of School Dates Taught Assignments














































REFERENCES:

Give as references at least three persons who are qualified to attest to your fitness for the position you seek. Include especially persons for whom you have taught and those who know your ability and character. DO NOT SAY, “REFER TO MY CREDENTIALS.”


Name Address Telephone Number


























Notice to applicants: Information that you provide on this application is subject to verification. Previous employers may be contacted as references. Do you want to be informed before we contact your present employer? Yes No

Name of Employer


Address of Employer
Job Title Dates employed
Immediate Supervisor(s) Phone No.
Full Time Part Time Volunteer

Describe your duties in detail (knowledge, skills, abilities required, employees supervised, accomplishments






Reason for Leaving

Name of Employer


Address of Employer
Job Title Dates employed
Immediate Supervisor(s) Phone No.
Full Time Part Time Volunteer

Describe your duties in detail (knowledge, skills, abilities required, employees supervised, accomplishments






Reason for Leaving





Name of Employer


Address of Employer
Job Title Dates employed
Immediate Supervisor(s) Phone No.
Full Time Part Time Volunteer

Describe your duties in detail (knowledge, skills, abilities required, employees supervised, accomplishments


Reason for Leaving
PERSONAL DATA:
Since you are applying for a position that involves working with children, please complete the following section:
Have you within the past seven years been released from prison or been convicted of any offense that involves any form of violence, such as assault, rape, child abuse, child molesting, extortion, blackmail, coercion, or any crime which involves drugs? Yes No If yes, explain nature of crime, place, and date.



Since you are applying for a position that may involve handling of money or Cooperative property, please complete the following section:
Have you within the past seven years been released from prison or been convicted of any offense that involved embezzlement, fraud, stealing, robbery, extortion, blackmail, or coercion?

Yes No If yes, please explain nature of crime, place and date.




Are you a veteran? Dates of Service Military Branch


Do you have a valid, current driver’s license? Yes No
IMPORTANT: Applications will not be considered eligible for consideration unless all requested information is on file. It is your responsibility to request your college or university to provide us with a transcript and placement file. Further, all information on the application form should be accurately completed. A five hundred (500) word handwritten autobiographical sketch covering your professional career is optional.
I hereby authorize Prickly Pear Cooperative to inquire as to my record with any or all of my former and/or current employers or references with no liability arising therefrom. I hereby guarantee the correctness of the above statements. The making of any false statement herein will be sufficient cause for dismissal. I also authorize the investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal.
SIGNATURE DATE SIGNED

APPLICANT SURVEY
Title VII of the U.S. Civil Rights Act requires the State of Montana to “make and keep records relevant to the determinations of whether unlawful employment practices have been or are being committed.” This is also a requirement of the Montana Human Rights Act and state and federal laws providing employment opportunities for veterans and persons with disabilities. The following survey helps to fulfill these requirements.
This applicant survey will be separated from your application. The survey information will be kept confidential, used only for computerized statistical reports and other lawful uses. Analysis of the information you and others provide will be used to monitor recruitment and selection practices in school government.
Name: Social Security No.

Mailing Address: City: State: Zip:

Home Phone No. E-Mail:

Date:

Sex: Female Male
ETHNIC GROUP – Please X the one box that best describes your ethnicity.
ALASKAN NATIVE-A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.
AMERICAN INDIAN-A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.
ASIAN or PACIFIC ISLANDER-A person having origins in any of the original peoples of the Indian Subcontinent, the Pacific Islands, or the Far East; for example, China, Japan, Korea.

BLACK (Not of Hispanic origin)-A person having origins in any of the Black racial groups of Africa.
FILIPINO -A person having origins in any of the original peoples of the Philippine Islands.
SPANISH AMERICAN-A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
WHITE (Not of Hispanic origin)-A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
OTHER-(Specify)

IMPORTANT: Your Application file will be considered incomplete without this sheet.






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