DATE
RECEIVED: ___________ INTERVIEW
DATE: __________
JOINT BOARD OF
CONTROL
Office Use
JACKSON RIVER TECHNICAL
CENTER
105 East Country Club Lane
Covington, Virginia 24426
(540)
862-1308
APPLICATION FOR EMPLOYMENT
Applicant’s Full
Name_______________________________________________________
(Last) (First) (M.I.) (Maiden Name)
Other
Name(s)_______________________________________________________________
(Please provide any
additional information relative to change of name, or nickname, necessary to
enable a check on your work or school record)
Present Mailing Address
_______________________________________________________
(Street) (City) (State) (ZIP)
Telephone Numbers:
Present: ( )
Permanent: ( _)_____________ Work: (
)_____________
Social Security
Number: ________________________ (Note: Completion of number is optional. Failure to submit social security number on this form will not
prohibit employment consideration.
Social Security number may be required on other forms prior to
employment.)
My signature below
authorizes the Joint Board to conduct a background investigation and authorizes
release of information in connection with my application for employment. This investigation may include such
information as criminal or civil convictions, driving records, previous
employers and education institutions, and the reference source from any
liability in connection with its release or use. This release includes the sources cited above and specific
examples as follows: the local Sheriff,
information from the Central Criminal Records Exchange of either data on all
criminal convictions or certifications that no data I\on criminal convictions
are maintained, information from the Virgin or other State Department of social
Services Child Protective Services Unit and any Locality to which they may
refer for release of information pertaining to any findings of child abuse or
neglect investigations involving me.
Furthermore, I
certify that I have made true, correct and complete answers and statements on
this application in the knowledge that they may be relied upon in considering
my application, and I understand that any omission, false answered statement
made by me on this application, or any supplement to it will be sufficient
grounds for failure to employ or for my discharge should I become employed with
the school division.
Date _______________________ Signature of applicant________________________________________
Are you a U.S. citizen? LIST BELOW POSITION FOR
WHICH YOU ARE APPLYING:
Yes ____ No ____ _______________________________________________
If not, are you eligible to work in the U.S.? _______________________________________________
Yes ___ No _____
THE JOINT BOARD IS AN
EQUAL OPPORTUNITY EMPLOYER
I.
EDUCATIONAL AND
PROFESSIONAL TRAINING (List Chronologically.)
Level of Type
of Year of Dates of Attendance
Education Name of
School or University State Field of Study Degree
Graduation
From…To________
High
School_______________________________________________________________________________________________________
College or
University_________________________________________________________________________________________________________
Trade or Tech-
nical
Schools______________________________________________________________________________________________________
Other Formal
Training__________________________________________________________________________________________________________
II.
STUDENT TEACHING
EXPERIENCE (List
chronologically and include any internships).
Position Held Dates Full Part
Name of School School Division Grades and /or Subjects Taught Mo./Day/Yr. Total
years Time Time Personnel Use
III. TEACHING EXPERIENCE (List chronologically and include any
internships)
___________________________________________________________________________
Position Held Dates Full Part
Name of School School Division Grades and /or Subjects Taught Mo./Day/Yr. Total years Time Time Personnel Use
IV, WORK
EXPERIENCE OTHER THAN TEACHING (List chronologically and attach a sheet if
necessary.)
Position Held Dates Full Part
Name of School School
Division Grades and /or Subjects
Taught Mo./Day/Yr. Total years Time Time Personnel Use
|
Employer City/County State Kind of Work Dates of Employment
Personnel Use |
|
|
|
|
|
|
|
|
|
|
V.
MILITARY EXPERIENCE
|
Branch of Service Occupational Specialist
(MOS) Inclusive
Dates Type of Discharge |
|
|
JACKSON RIVER TECHNICAL CENTER
105
E. Country Club Lane
Covington,
Virginia 24426
(540) 862-2308
Date _________________
FROM: (Applicant)
TO: Whom It May Concern
I hereby authorize my former employers and/or references to release to Jackson River Technical Center, Covington, Virginia, any information which may be pertinent to my application for employment with Jackson River Technical Center.
Signature
Memo to: Applicant for Jackson River Technical Center Position
From: Sue Wolfe, Clerk
Re: Employment Prerequisites
Pursuant to Virginia School and State Laws, the following are conditions to employment with Jackson River Technical Center:
1. Every employee shall submit a certificate signed by a licensed physician that such employee appears free of communicable tuberculosis.
2. Every employee shall submit a completed “Request for Search of the Central Registry and Release of Information Form” along with a cashier’s check or money order in the amount of $5.00 payable to Virginia Department of Social Services.
3. Every employee shall submit to a background check by being fingerprinted. This will require completing proper paperwork with Alleghany County Schools. Directions for fingerprinting procedures will be given upon completion.
These prerequisites are not necessary until notification of employment has been received.