Bellefonte Area School District

Bellefonte Area School District

318 North Allegheny Street

Bellefonte, PA 16823

www.basd.net (814) 355-4814

APPLICATION FOR SUPPORT SERVICES

Date of Application___________________________

Position (s) Applied For

Maintenance

Custodial

Secretary/Clerical

Assistant

Cafeteria

Other__________________

Name

Address

Telephone

Social Security Number

Yes

Have you filed an application at Bellefonte Area School District before?

Are you employed now?

May we contact your present employer?

Are you on layoff subject to recall?

Are you a veteran of the US Military Service? If yes, which branch?

Have you been convicted of a felony within the last seven (7) years?

(A conviction will not necessarily disqualify an applicant from employment). If yes, explain in the box below.

Email (if available): _______________________________________________________________________________

On what date would you be available for work?___________________________________________________

Are you available to work (check all that apply)

□ Full Time □ Part Time □ Substitute

Employment Record

Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which

indicate race, color, religion, sex, national origin, or disability. Bellefonte Area School District will contact supervisors and other individuals listed in your employment records.

Employer Telephone

Date Employed

Work Performed

From

^Address

^{Job Title}

Hourly Rate/Salary

^Supervisor

Starting

Final

Reason for leaving

Employer Telephone

Date Employed

Work Performed

From

^Address

^{Job Title}

Hourly Rate/Salary

^Supervisor

Starting

Final

Reason for leaving

Employer Telephone

Date Employed

Work Performed

From

^Address

^{Job Title}

Hourly Rate/Salary

^Supervisor

Starting

Final

Reason for leaving

Employer Telephone

Date Employed

Work Performed

From

^Address

^{Job Title}

Hourly Rate/Salary

^Supervisor

Starting

Final

Reason for leaving

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not, and is not intended to be, a contract of employment.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in dismissal. I also understand that I am required to abide by all rules and regulations of the Bellefonte Area School District.

As a measure to prevent child abuse, the Pennsylvania State Legislature passed Act 151 (Child Abuse History) and Act 34 (Criminal Background) and Act 114 (FBI Criminal History Records - Fingerprint) which requires a prospective employee who would work directly with children to secure a background check from the Pennsylvania Department of Welfare and the Pennsylvania State Police, and a check completed through the

Pennsylvania Department of Education by the Federal Bureau of Investigation. Please check the appropriate statement.

□ I have attached copies of the background checks from the Pennsylvania Department of Welfare, Pennsylvania State Police, and the FBI Fingerprint dated _______________/______________/_______________ and I understand that if employed, I must submit the original.

□ I have requested background checks from the Pennsylvania Department of Welfare, the Pennsylvania State Police and the FBI Fingerprint and will forward the reports to the Bellefonte Area School District when received.

□ As an out-of-state applicant, I have attached/requested an FBI background check record.

Signature of Applicant ___________________________________________________________

Date ___________________________

To comply with Federal laws (including Title IX of Education Amendments of 1972), state laws, and State Department of Education regulations concerning equal opportunities and to assure these within our school community, the Bellefonte Area School District declares itself to be an Equal Rights and Opportunities District. It does not discriminate against individuals or groups because of race, color, national origin, religion, age, sex, marital status, or non-relevant handicaps and disabilities. The district’s commitment to non-discrimination extends to students, employees, prospective employees, and the community. Applicants requiring assistance in completing this application should contact the Personnel Office. For information regarding civil rights or grievance procedures, services, activities, and facilities accessible to and useable by handicapped persons, contact the Title IX Coordinator/District’s Civil Rights Compliance Officer: Dr. Cathy Brachbill, Director of Curriculum and Instruction, 318 N. Allegheny Street, Bellefonte, PA 16823-1679 (814-355-4814).