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

 

No

 

 

 

 

 

 

 

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.

1

 

Employer                                           Telephone

 

Date Employed

 

Work Performed

 

From

 

To

 

Address

 

 

 

 

 

 

 

Job Title

 

Hourly Rate/Salary

 

 

 

Supervisor

 

Starting

 

Final

 

 

 

Reason for leaving

 

 

 

 

 

 

2

 

Employer                                           Telephone

 

Date Employed

 

Work Performed

 

From

 

To

 

Address

 

 

 

 

 

 

 

Job Title

 

Hourly Rate/Salary

 

 

 

Supervisor

 

Starting

 

Final

 

 

 

Reason for leaving

 

 

 

 

 

 

3

 

Employer                                           Telephone

 

Date Employed

 

Work Performed

 

From

 

To

 

Address

 

 

 

 

 

 

 

Job Title

 

Hourly Rate/Salary

 

 

 

Supervisor

 

Starting

 

Final

 

 

 

Reason for leaving

 

 

 

 

 

 

4

 

Employer                                           Telephone

 

Date Employed

 

Work Performed

 

From

 

To

 

Address

 

 

 

 

 

 

 

Job Title

 

Hourly Rate/Salary

 

 

 

Supervisor

 

Starting

 

Final

 

 

 

Reason for leaving

 

 

 

 

 

 

 


 

Special Skills and Qualifications

 

Summarize special skills and qualifications acquired from employment or other experience.  Also describe office equipment or tools of the trade you are familiar with that apply to the position you seek.

 

 

 

 

 

 

 

Education

 

 

 

School Name

 

Years Completed

 

Diploma/Degree

 

Describe Course of Study

 

Elementary

 

 

 

   4      5      6      7      8

 

 

 

 

 

High School

 

 

 

9     10     11     12

 

 

 

 

 

Trade School/

College

 

 

 

1     2     3     4

 

 

 

 

 

Extra Curricular Activities, Interests, and Skills

 

Describe any extra curricular activities.

 

 

 

 

 

 

 

References

 

List people who have supervised your work or others who have personal knowledge of your qualifications, character and ability.  Bellefonte Area School District will contact individuals listed.

 

Name

 

Address

 

Telephone

 

Position

 

 

 

 

 

(H)

(W)

 

 

 

 

 

 

 

(H)

(W)

 

 

 

 

 

 

 

(H)

(W)

 

 

 

 

 

 

 

(H)

(W)

 

 

 

 

 

 

 

(H)

(W)

 

 

 

 

 

Applicants Statement

 

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.

 

______________________________________            _________________________

   Signature of Applicant                                                        Date

 

Applications are not kept on file after a vacancy has been filled.

 

 

ACT 151/ACT 34 COMPLIANCE

Background Check of Prospective Employees

                                       

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 districtís 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/Districtís Civil Rights Compliance Officer: Dr. Cathy Brachbill, Director of Curriculum and Instruction, 318 N. Allegheny Street, Bellefonte, PA 16823-1679 (814-355-4814).

 

 

 

 

                                                    

Applications are not kept on file after a vacancy has been filled.