JEFFERSON UNION HIGH SCHOOL DISTRICT

ADMINISTRATIVE OFFICES – SERRAMONTE DEL REY

699 Serramonte Boulevard, #100, Daly City, California   94015

Phone:  (650) 550-7900         Fax:  (650) 550-7888          www.juhsd.k12.ca.us

 

CERTIFICATED   EMPLOYMENT   APPLICATION

 

Public Law 99-603 (Immigration, Naturalization and Control Act of 1986) requires that all employees hired after November 6, 1986 provide proof of work eligibility. Therefore, if hired please be prepared to present appropriate documentation verifying identity and ability to work legally in the United States.

 

In completing this application please be reminded that the law protects the rights for equal employment opportunity regardless of race, creed, color, sex, age, physical handicap, or national origin; employment acceptance or rejection shall be based on job related qualifications. An incomplete application may disqualify the applicant.

 

ALL SECTIONS MUST BE COMPLETED EVEN IF YOU SUBMIT A RESUME.   PLEASE TYPE OR PRINT CLEARLY.

 

POSITION APPLIED FOR: __________________________________________________                                             DATE FILED _____________

 

Dr. ____   Mr.____   Mrs.____   Ms. ____   Miss _____            Social Security Number: ___________________________

 

Name: _____________________________________________________________________________________________

                                last                                                       first                                                      middle

 

Address: __________________________________________________________________________________________

                                Number                                Street                                                  City                       State                    Zip

 

Telephone:            Home:                                                                                     Work:                                                                                    

 

CREDENTIALS NOW HELD: __________________________________________     EXPIRATION:                                         

 

  CA                     OTHER                                                           CLAD/BCLAD CERTIFICATE:                                                        

                                                                                                                LDS/BCC CERTIFICATE:                                                  

EDUCATIONAL AND PROFESSIONAL TRAINING

 

 

 

 

NAME & LOCATION OF COLLEGE OR UNIVERSITY

MAJOR

MINOR

DEGREE/YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEACHING EXPERIENCE

 

 

 

 

 

 

NAME OF SCHOOL

SCHOOL DISTRICT, CITY/STATE

POSITION HELD- SUBJECTS TAUGHT

DATES FROM...TO

TOTAL YEARS

FULLTIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADMINISTRATIVE EXPERIENCE

 

 

 

 

 

 

NAME OF SCHOOL

SCHOOL DISTRICT, CITY/STATE

POSITION HELD- SUBJECTS TAUGHT

DATES FROM...TO

TOTAL YEARS

FULLTIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If there is someone that will know your whereabouts, please indicate below.

                Name                                                                                                      Telephone:                                                                           

REFERENCES:

 

 

 

 LIST FOUR PERSONS WHO HAVE PROFESSONAL KNOWLEDGE OF YOUR TRAINING AND EXPERIENCE

 

NAME

OFFICIAL POSITION

PRESENT ADDRESS

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has your credential ever been suspended or revoked?                                                                                                    Yes      No

Have you ever been investigated for any behavior or conduct while employed in a school district?                      Yes      No

                If yes, please explain on a separate sheet of paper.

Has any action ever been taken against you by a teacher’s licensing agency?                                                           Yes      No

                If yes, please explain on a separate sheet of paper.

Have you ever left a regular certified position at any time other than the end of the school year?                           Yes      No

Have you ever been dismissed or asked to resign from any certified position?                                                           Yes      No

Have you ever been convicted of a crime other than a minor traffic violation, misdemeanor or summary offense?                  Yes      No

Have you any physical disability or infirmity which may prevent you from effectively performing                          Yes      No

the duties of this position?

Have you ever been a member of California State Teachers’ Retirement System?                                                       Yes      No

                If yes to the above what school district and county: ________________________________________

 

Describe briefly any special experience which you feel would add to your value as an employee.

 

 

 

 

 

Please add any further information you feel is pertinent to your application, noting preparation and experience in subject or areas of activities.

 

 

 

 

 

My placement papers are on file with the following placement office:

 

 

 

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To the Applicant: The information in this section is voluntary. It is requested under the conditions of section 1233 of the Calif. Government code which permits the collection of ethnic background data on employment applicants. This data is to be used solely for implementing and improving our affirmative action program and will have no bearing on your application. This sheet is coded according to the position for which you are applying, not according to name; it will be placed separately in a non-public file; accessible only for research purposes.

Please check the appropriate box.                     Sex:          Male                  Female

 

Ethnic Background:              Asian                Black                 Caucasian         Filipino              American Indian

                                                 Pacific Islander                                Spanish Surname                            Other

 

I hereby certify that all statements made in this application are true to the best of my knowledge.

 

                                                                                                                                                                                                                               

                Signature of Applicant                                                                                        Date

04/08