Employment Application

Full Name

First Name Last Name

SSN

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Contact Phone Number

Area Code Phone Number

Secondary Phone Number If Applicable

Area Code Phone Number

E-mail

Position Applying

How did you hear about the position?

Date Available

Month Day Year

Expected Salary

Expected Hourly Rate

What type of position are you interested in?

FullPart-TimeSub

If you chose Part-Time, which of the following interests you?

2-3 days a week1/2 days

Are you entitled to work in the United States?

YesNo

Are you 18 or older?

YesNo

If Yes, Date of Birth

Have you been convicted of a felony or been incarcerated in connection with a felony in the past seven years?

YesNo

If Yes, please explain

Military Service?

YesNo

Branch

Are you a smoker?

YesNo

Employer 1: Company Name

Employer 1: Supervisor Name

Supervisor 1:E-mail

Employer 1: Position/Job Title

Employer 1: Reason for Leaving

Employer 1: Pay

Employer 1: Dates of Employment

Employer 1: Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer 1: Phone Number

Area Code Phone Number

Employer 1: May We Contact

YesNo

Employer 2: Company Name

Employer 2: Supervisor Name

Supervisor 2:E-mail

Employer 2: Position/Job Title

Employer 2: Reason for Leaving

Employer 2: Pay

Employer 2: Start Date

Month Day Year

Employer 2: End Date

Month Day Year

Employer 2: Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer 2: Phone Number

Area Code Phone Number

Employer 2: May We Contact

YesNo

Employer 3: Company Name

Employer 3: Supervisor Name

Supervisor 3:E-mail

Employer 3: Position/Job Title

Employer 3: Reason for Leaving

Employer 3: Pay

Employer 3: Start Date

Month Day Year

Employer 3: End Date

Month Day Year

Employer 3: Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer 3: Phone Number

Area Code Phone Number

Employer 3: May We Contact

YesNo

High School School Name, Location, Grade Completed

College/University School Name, Location, Years Completed

Did you graduate?

YesNo

Type of Degree Earned

Trade School/Other School Name, Location, Degree/Diploma

List any applicable special skills, training or proficiencies.

List all areas in which you hold valid FL and/Or out-of-state teaching certificates.

Reference 1: Name

First Name Last Name

Reference 1: Relation

Reference 1: E-mail

Reference 1: Phone Number

Area Code Phone Number

Reference 2: Name

First Name Last Name

Reference 2: Relation

Reference 2: E-mail

Reference 2: Phone Number

Area Code Phone Number

Reference 3: Name

First Name Last Name

Reference 3: Relation

Reference 3: E-mail

Reference 3: Phone Number

Area Code Phone Number

Please note that this application is NOT complete until a resume is submitted to [email protected]. After submitting this application, please immediately email your resume.

Were you ever convicted of a criminal offense?

YesNo

Are you currently under charges for a criminal offense?

YesNo

Have you ever forfeited bond or collateral in connection with a criminal offense?

YesNo

Within the last ten years, have you quit a job after being notified that you would be fired?

YesNo

Within the last ten years, have you been fired from any job for any reason?

YesNo

Have you ever been professionally disciplined in any state?

YesNo

Professional disciplined means the annulment, revocation or suspension of your teaching certification or having received a letter of reprimand from an agency, board or commission of state government.

Are you subject to any visa or immigration status, which would prevent lawful employment?

YesNo

Have you ever had your license suspended?

YesNo

Note: if you answered "Yes" to any of the above questions, please email a detailed explanation to [email protected] including dates.

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 further certify that I am the sole author of the essay. 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 officials of my listed school district(s) may ask 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 this school district. 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 information regarding my background. However, I do not authorize the production of medical records or other information related to any medical condition or medical history., which would tend to actually identify a disability nor do I authorize inquiries which would include information related to any medical condition or history. Further, I do not waive my 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 for employment discrimination because of race, color, sex, religion, national origin, ancestry, age or disability.

Disclaimer - By digitally signing, I hereby certify that the above information, to the best of my knowledge, is correct. I understand that falsification of this information may prevent me from being hired or lead to my dismissal if hired. I also provide consent for former employers to be contacted regarding work records.

Full Name

First Name Last Name

EHA Employment Application

Personal Information

Prior Work History

Employer 1

Employer 2

Employer 3

Education

Certfication

References

General Background Information

Criminal Offense

Conviction