2525 Lake Helena Drive
“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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