Employment Application Form - Northeast Bradford School District (Page 2 of 2) in pdf

EMPLOYMENT HISTORY

(List all full and part-time employment beginning with current or most recent)

Employer and Address

Dates of Employment

Position/Assignment

REFERENCES

(Please give the names of at least 3 persons who have first hand knowledge of your character, personality and abilities.)

Name and Address

Position

Telephone Number(s)

I authorize the Northeast Bradford School District to contact former employers and/or references listed to secure information relative to my employment with

Northeast Bradford School District. I authorize my present and/or previous employer(s) to provide reference information to Northeast Bradford as requested. I

certify that the above statements are true to the best of my knowledge and understand that the making of any false statement will be considered sufficient cause

for non-employment or termination of my employment.

__________________________________________________________________________________

Signature of Applicant

Date

ACT 34 COMPLIANCE (Background Check of Prospective Employees)

All Pennsylvania residents must submit with their 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. If you are an out-of-state resident

or have been a Pennsylvania resident for less than two years, you must submit a copy of a federal criminal record history report from the Federal Bureau of

Investigation with your application. The criminal record history report must be no more than one (1) year old and upon hiring the applicant MUST submit the

ORIGINAL report.

ACT 151 COMPLIANCE (Pennsylvania 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.

ACT 24 SECTION 111

This standardized form (PDE-6004) has been developed by the Pennsylvania Department of Education, pursuant to 24 P.S. §1-111(j), to be used by current and

prospective employees of public and private schools, intermediate units and area vocational-technical schools for the written reporting by current and prospective

employees of any arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) and (f.1).

FBI FEDERAL CRIMINAL HISTORY RECORD

Applicants are required to submit with the application for employment a copy of the federal criminal history record in a manner prescribed by the Department of

Education. When the applicant provides a copy of the federal criminal history record, it shall be no more than one year old at the time of employment.

NONDISCRIMINATION POLICY

Northeast Bradford School District is an equal opportunity education institution and will not discriminate on the basis of race, color, national origin, sex and

handicap in its activities, programs or employment practices as required by Title VI, Title IX, and Section 504. For information regarding civil rights or grievance

procedures, contact SUPERINTENDENT, Title IX, Title VI, and Section 504 Coordinator, at the Northeast Bradford School District, 526 Panther Lane, Rome, PA

18837 (570-744-2521).

Employment Application Form - Northeast Bradford School District Page 2

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