Southern Tioga School District

241 Main Street, Blossburg, PA 16912-1155

(570) 638-2183

Support Staff Employment Application Form

DATE:

Position for which you are applying:

NAME: Social Security No.:

Last First Middle

Address:

Street City State Zip

Home Telephone: ( ) Daytime Telephone: ( ) County

EDUCATION:

	SCHOOL	ADDRESS	DATES ATTENDED	DEGREE/CERTIFICATE
Secondary
College
Other

Are you over 18 years of age? yes no If not, employment is subject to verification of minimum legal age.

If you are presently employed, please state reason(s) a new position is being sought:

When will you be available to begin work?

Will you work overtime if asked? yes no

What is the minimum salary/wage that is acceptable to you?

Special Training/Skills: Summarize special job-related skills and qualifications acquired from employment or other experiences (including U.S. military service. Also state any additional information you feel may be helpful in considering your application, i.e. honors, awards, activities, technology skills, or special training.

The Southern Tioga School District is an equal opportunity employer in compliance with Title IX, Title VI, and Act 504.

EMPLOYMENT HISTORY: (include military service, if any)

COMPANY NAME ADDRESS TELEPHONE

Employed from to

JOB TITLE NAME OF SUPERVISOR

DESCRIBE YOUR RESPONSIBILITIES

REASON FOR LEAVING:

COMPANY NAME ADDRESS TELEPHONE

Employed from to

JOB TITLE NAME OF SUPERVISOR

DESCRIBE YOUR RESPONSIBILITIES

REASON FOR LEAVING:

COMPANY NAME ADDRESS TELEPHONE Employed from to JOB TITLE NAME OF SUPERVISOR DESCRIBE YOUR RESPONSIBILITIES REASON FOR LEAVING:
COMPANY NAME ADDRESS TELEPHONE Employed from to JOB TITLE NAME OF SUPERVISOR DESCRIBE YOUR RESPONSIBILITIES REASON FOR LEAVING:
	May we contact your former employers? yes no If no, please state which ones and why.

REFERENCES:

NAME

ADDRESS

TELEPHONE

RELATIONSHIP TO YOU

ACT 34 (Criminal Record Check)

Each Pennsylvania resident must submit with his/her employment application a copy of a report of Criminal History Record Information from the Pennsylvania State Police or a statement from the Pennsylvania State Police that the State Police Central Repository contains no such information relating to that person. Each out-of-state applicant must submit with his/her application for employment a copy of a federal criminal record history from the Federal Bureau of Investigation. The criminal record history report must be no more than one (1) year old. The applicant MUST submit the ORIGINAL report prior to employment.

ACT 151 (PA Child Abuse History Clearance)

Each candidate must submit with his/her employment application a copy of an official clearance statement obtained from the Pennsylvania Department of Public Welfare or a statement from the Department of Public Welfare that no record exists. The clearance statement must be no more than one (1) year old. The applicant MUST submit the ORIGINAL report prior to employment.

TO COMPLETE YOUR APPLICATION PORTFOLIO:

The following items must be submitted to complete your application portfolio:

Letter of Application Current* Act 34 Criminal Record Check

Current Resume Current* Act 151 Child Abuse History Clearance

Completed Southern Tioga Application

I-9 Employment Eligibility Verification *current=less than one year old at time of hire

(If unable to come to the office, please

include a copy of your driver’s license and

social security card with the completed

I-9 form)

APPLICANT SIGNATURE:

The information provided on this application and accompanying information is true and complete to the best of my knowledge and I agree that falsified information or omissions may disqualify me from employment and may be justification for dismissal if discovered at a later date.

APPLICANT SIGNATURE DATE