 The
Ida B. Wells Community Academy, Inc. We Are An
Equal Education and Employment Employment Application for 2004 - 2005 Mail or FAX completed Application to: Ms. Angela M. Neeley, Chief Administrative Officer 1180 Slosson Street, Akron, Ohio 44320-2730 Phone: 330.867.1085 FAX: 330.867.1074 Please print or type your
information Date _________________________ Name
_________________________________________________________________________________
Business Telephone ( ) ___________________ Home Telephone ( ) ____________________ Social Security No. _______________________________________________ Present Address
_____________________________________________________________________________
Permanent Address (if different from present address) __________________________________________________________________________________________
EMPLOYMENT DESIRED Position you are applying for: ___________________________________________________________________ Are you applying for: Regular full-time employment? . . . . . . . . . . . . . . . . . . . Yes _____ No _____ Regular part-time employment? . . . . . . . . . . . . . . . . . . Yes _____ No _____ Volunteer employment? . . . . . . . . . . . . . . . . . . . . . . . . . Yes _____ No _____ If you are asked, what days and hours are you available to volunteer? ________________________________________________________________________________________ If applying for volunteer employment, during what periods of time will you be available? From
_______________________ To ________________________
Are you available to volunteer on weekends? . . . . . . . . . . . . . . . . Yes _____ No _____ Would you be available to work after hours, if necessary? . . . . . . . Yes _____ No _____ If hired, on what date can you start? ___________________________________________________________ Salary (or hourly rate) desired for regular, non-instructional employment only: ______________________________________________________________________________________ PERSONAL INFORMATION Have you ever applied to or worked for the Ida B. Wells Community Academy? Yes ________ No ________ If yes, when? ___________________________________________________________________________ Do you have any relatives employed by the Ida B. Wells Community Academy? Yes____ No ____ If yes, give name(s) and relationship _________________________________________________________ Why are you applying for employment at the Ida B. Wells Community Academy? _____________________________________________________________________________________ If hired would you have a reliable means of transportation to and from work? . . Yes _______ No _______ Are you at least 18 years old? . . . .
. . . . .
. . . . . . . . .. . . . . . . . . . . . . . . . . Yes
_______
No _______ If hired, can you present evidence of
your U.S. citizenship
or proof of your legal right to live and
work in the United Are you able to perform the essential functons of the job you are applying for? . .Yes _______ No ______ If no, describe the functions that cannot be performed. ___________________________________________ _____________________________________________________________________________________ NOTE: We comply with the ADA and Workers
Compensation and we
consider reasonable accommodation Have you ever been convicted of a crime (felony or serious misdemeanor)? . . . . . . .Yes _______ No _______ If yes, state nature of the crime(s); when and where convicted and disposition of the case. _____________________________________________________________________________________ _____________________________________________________________________________________ In order to be employed by the Ida B. Wells Community
Academy, you must
submit a Bureau of Criminal Are you currently employed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes _______ No _______ If so, where and may we contact your
current employer?
. . . . . . . . . . . . . . . . . . .Yes _______ No _______
EDUCATION AND TRAINING EXPERIENCE
Do you speak, write or understand any foreign languages? . . . . . . . . . . . . . . . . . Yes _______ No _______ If yes, which language(s)? ____________________________________________________________ Do you have any other experience. Training, qualifications or skills which you feel make you especially suited for employment at the Ida B. Wells Community Academy? If so, please explain: _________________________________________________________________________________ _________________________________________________________________________________ Answer the following questions if you are applying for professional position. Are you licensed/certified for the position applied for? . . . . . . . . . . . . . . . . . . . . . .Yes _______ No _______ Name of license/certification __________________________________________________________ Issuing state(s) ____________________________________________________________________ License/certification number(s) ________________________________________________________ Has your license/certification ever been revoked or suspended? . . . . . . . . . . Yes _____ No _____ If yes, state reason(s), date of revocation or suspension and date of reinstatement. ______________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________ Name(s) and telephone numbers of person(s) to be contacted in case of emergency. Name ______________________ Phone No. _______________ Relationship _____________ Name ______________________ Phone No. _______________ Relationship _____________ EMPLOYMENT HISTORY List below three present and past
employment starting
with your most recent employer (last 10 years is 1. Name of Employer ______________________________________________________________ Address
__________________________________________________________________________ Type of Business ___________________________________________________________________ TeIephone No. ____________________ Your Supervisor's Name _____________________________ Your Position and Duties _____________________________________________________________ Date of Employment: From ____________________________ To _____________________________ Weekly Pay; Starting ___________________________ Ending _____________________________ Reason for Leaving _________________________________________________________________ 2. Name of Employer ____________________________________________________________ Address
__________________________________________________________________________
Type of Business ___________________________________________________________________ TeIephone No. ______________________ Your Supervisor's Name ___________________________ Your Position and Duties _____________________________________________________________ Date of Employment: From ______________________________ To ___________________________ Weekly Pay; Starting ___________________________ Ending _____________________________ Reason for Leaving _________________________________________________________________ 3. Name of Employer ______________________________________________________________ Address
__________________________________________________________________________
Type of Business ___________________________________________________________________ TeIephone No. _____________________ Your Supervisor's Name ____________________________ Your Position and Duties _____________________________________________________________ Date of Employment: From _________________________ To ________________________________ Weekly Pay; Starting ____________________________ Ending _____________________________ Reason for Leaving _________________________________________________________________ MILITARY SERVICE Have you obtained any skills or abilities as a result of service in the military? . . Yes ______ No ______ If so, describe _____________________________________________________________________ ________________________________________________________________________________ REFERENCES List below three persons not related
to you who have
knowledge of your work performance or character within 1. Name _______________________________________________________________________ Address
_________________________________________________________________________
Occupation _______________________________________________________________________ TeIephone No. ( ) ___________________ Number of Years acquainted ______________________ 2. Name _______________________________________________________________________ Address
_________________________________________________________________________
Occupation _______________________________________________________________________ TeIephone No. ( ) ___________________ Number of Years acquainted ______________________ 3. Name _______________________________________________________________________ Address
_________________________________________________________________________
Occupation _______________________________________________________________________ TeIephone No.
( ) ___________________
Number of Years acquainted ______________________ Please Read Carefully, Initial Each Paragraph and Sign Below __________ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I further understand that this applies specifically to a Bureau of Criminal Investigation check which reports I have committed serious criminal offenses within a ten-year period. If such a report comes to the attention of the Principal, Superintendent and the Academy's Board of Governors after I am hired, the Board shall deliberate on the matter and decide to retain or discharge me. __________ I hereby authorize the Ida B. Wells Community Academy to thoroughly investigate rny references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the Ida B. Wells Community Academy any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Ida B. Wells Community Academy, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. __________
I understand that nothing contained in
the application, or conveyed during any interview which may be granted or during my employment, if hired, is
intended to create an employment contract between me and the Ida B. Wells Community Academy. In addition,
I understand and agree that if I am employed, my ernployrnent is for no definite or determinable
period and may be terminated at any time with or without prior notice and at the option of the Board of Governors
of the Ida B. Wells Community Academy. I also understand that no promises or representations contrary to
the foregoing are binding on the Ida B. Wells Community Academy unless made in writing and signed by me
and the Ida B. Wells Community Academy's designated
representative.
AUTHORIZATION The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement or omission of information on this application may result in my disqualification or dismissal. I further understand that this is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides not to employ me. You are hereby authorized to make any investigation of my personal history and financial and credit record* through any investigative or credit agencies or bureaus of your choice. I hereby fully waive any rights or claims I have or may have against all current and/or former employers, and their agents, employees and representatives, and damages that may directly or indirectly result from the use, disclosure or release of any such information by any person or party, whether such information is favorable or unfavorable to me. I further waive any claim against the Ida B. Wells Community Academy as a result of any information which it obtains in this investigation. A copy of this document is the same as an original. In making this application for employment, I authorize you to undertake an investigative consumer report whereby information is obtained through personal interviews with my neighbors, friends, or others with whom I am acquainted. This inquiry, if made, may include information as to my character, general reputation, personal characteristics and mode of living. I understand I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of any such investigative report that is made. Date _____________________ Signature of Applicant _____________________________________________ *Should
a consumer credit report be processed, you
are entitled to receive a copy. Please Initial your response below.
Yes ________ No ________ ACADEMY
FORM 01 (Revised
October 17, 2002)
|