Universal Application For Marin County School Districts Certificated Employment (Page 2 of 2) in pdf

Have you ever been convicted of any felony or misdemeanor, fined, or placed on probation?

Yes

(exclude minor traffic violations)

Are you currently using controlled substances without a prescription and/or are you an active alcoholic?

Yes

Do you have any relatives working for the district?

Yes

Are you currently, or have you ever been a member of STRS or PERS?

Yes

Has your credential ever been suspended or revoked?

Yes

Have you ever been dismissed or asked to resign from any teaching position?

Yes

If you worked for the district under a different name,

what was your former name? __________________________________________________________

(For each question answered yes, explain in writing the circumstances and attach the statement to this form or write below)

Please list any training, skills, experiences, professional activities or special qualifications not shown on this form that you have gained through

volunteer, community, or other activities; list qualifications which especially equip you to work with culturally diverse environments and/or multi-

ethnic communities, and include a brief explanation; use this space for any other item you wish to explain in further detail.

REFERENCES: Please list the names and current phone numbers of three people who have directly supervised your work in the

positions listed on this application. You may also submit additional references.

Name

Employer/Company

Home Phone

Work Phone

I hereby authorize the district to fully investigate my record and work qualifications either before or after my employment and to facilitate such

investigation. I also hereby authorize any persons having knowledge thereof to give such information to the district upon request. I release from all

liability persons and organizations reporting information required by this application. I certify that all statements made by me on this application for

employment are true and correct to the best of my knowledge and belief and agree that if employed, any misrepresentation, falsification, or omission of

facts thereon shall justify my dismissal. I further agree that as a condition of employment, I shall submit to an Oath of Office, fingerprinting, and an

examination to determine freedom from active tuberculosis. I shall abide with the provisions of Penal Code Section 11166 and Welfare and Institution

Code, Section 15630. Please note that smoking is not permitted in any district building. In compliance with the Immigration Act of 1986, you must

submit prior to employment your Social Security card and valid driver’s license or State Identification Card.

Signature: ________________________________________________________

Date ______________________________

How did you learn about this job?

Applicant’s Name:

Schools employee

Mailing Address:

Internet/Job Hotline

Number Street

State Employment Office