MSAD #37

Office of the Superintendent

PO Box 79

Harrington, Maine 04643

Telephone (207) 483-2734

Fax: (207) 483-6051

APPLICATION FOR NON-TEACHING POSITION

MSAD #37 does not discriminate in the operation of its educational and employment policies and will honor all appropriate laws relative to discrimination.

Date _______________________	Position(s) applying for:
Name_______________________________________________	_________________________________________
Social Security Number __________________	Location:
When will you be available? ________________	_________________________________________
Permanent Address ____________________________________	Phone ___________________
Temporary Address ____________________________________	Phone ___________________

EDUCATION: Starting with high school, list any schools or colleges you may have attended.

School attended

Address

No. of Years

Graduated / Degree

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

EXPERIENCE: Pleas list all previous employment starting with the most recent job held. Use separate sheet if necessary. Please account for any gaps in employment during the last 10 years on a separate sheet.

From	To	Position	Duties	Employer
(Month/year)

BACKGROUND:

Have you ever been disciplined, discharged, asked to resign, or failed to receive a continuing contract appointment from a prior position?

Yes _______ No _________

Have you ever resigned from a prior position after a complaint had been received against you or your conduct was under investigation or review?

Yes ______ No _______

Has your contract in a prior position ever been non-renewed?

Yes _______ No ________

Have you ever not been nominated for re-employment in a prior position or ever had your nomination for re-employment not be approved?

Yes _______ No _________

Have you ever been charged with or investigated for sexual abuse or harassment of another person?

Yes _______ No _________

Have you ever been convicted of a crime (other than a minor traffic offense)?

Yes _______ No _________

Have you ever entered a plea of guilty or "no contest" (nolo contendere) to any crime (other than a minor traffic offense)?

Yes _______ No _________

Have you ever had a professional license or certificate suspended or revoked in any state, or have you ever voluntarily surrendered, temporarily or permanently, a professional license or certificate in any state?

Yes _______ No _________

Has any court ever deferred, filed or dismissed proceedings without a finding of guilty and required that you pay a fine, penalty or court costs and/or imposed a requirement as to your behavior or conduct for a period of time in connection with any crime (other than a minor traffic offense)?

Yes _______ No _________

If you answered YES to any of the previous questions, provide full details on an additional sheet including, with respect to court actions, the date, offense in question, and the address of the court involved. Conviction of a crime is not an automatic bar to employment.

REFERENCES: List three, two of whom are most recent supervisors, who can comment on your ability and whom we may contact. In addition, please provide three letters of reference from persons who are not related to you (may be from references listed below).

Name Position Address Phone

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

My signature below constitutes authorization to check my employment history, including without limitation, criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any state, local or federal agency. I further authorize those persons, agencies or entities that MSAD #37 contacts in connection with my employment application to fully provide MSAD #37 any information on the matters set forth above. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against MSAD #37, its agents and officials or against any provider of such information.

I understand that information submitted in and with this application may be disclosed to a screening and/or interviewing committee, which may include board members, administrators, other staff, and members of the community. I give my consent to this disclosure.

Signature _____________________________ Driver’s License # ___________________

Date __________________

Application Check list: The completed employment application cannot be evaluated unless all of the following materials have been provided:

_______ Application form fully completed and signed (4 Pages)

_______ Gaps in employment during the past ten years explained

_______ YES to any of the questions in the Background section explained

Applications will remain active for a period of 12 months from date of receipt. All materials become the property of MSAD #37. None will be returned. Any falsification of information or misleading information on this application shall be fully sufficient grounds to refuse to employ or, having been employed, shall be immediate cause for dismissal.