Arickaree School District R-2

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Classified Staff Position

Email *

Today's Date: *

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Date Available: *

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Applicant's Full Name *

Other names that files may be listed under:

Present Mailing Address: *

Permanent Mailing Address ( If Different)

Contact in an Emergency: *

E-Mail Address and Telephone Number: *

What positions are you applying for? *

Name of College or High School, Location, and Graduation Year: *

Work Experience: Dates From Year to Year, Job Name & Location, and position held. *

Please describe your qualifications for the position you are applying for. *

Reference 1: Name of Reference, Position / Relationship, and phone number *

Reference 2: Name of Reference, Position / Relationship, and phone number *

Reference 3: Name of Reference, Position / Relationship, and phone number *

Have you ever been convicted of a felony, pleaded nolo contendere or received probation for any offense involving moral turpitude (includes, but is not limited to such offenses as theft, attempted theft, murder, rape, embezzlement, and indecency with a minor)? If YES, state the nature of the offense, the date of the conviction, the name and address of the court, and pertinent details: *

Have you ever been involuntarily terminated or asked to resign from the employment of a school district? If Yes, please explain further. *

Have you ever reached a mutual decision with an employing school district to vacate a contract prior to its expiration? If Yes, please explain further. *

Are you aware of any reason you would not be able to perform the duties required of the position for which you are applying? If Yes, please explain further. *

AGREEMENT: I hereby certify that all statements made on this application are true, accurate, and complete. Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty of perjury in the second degree as defined in Section 18-8-503, C.R.S., and, upon conviction thereof, shall be punished accordingly. Any misrepresentation or willful omissions of facts shall be sufficient cause for disqualification of the application or termination of employment. I hereby authorize the district or its agents to conduct work history and personal reference checks to verify statements on this application form and other materials provided as part of my application for this position and release from liability anyone providing such information. Sign Below *

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