Application Form - Forsyth Country Day School

Forsyth Country Day School5501 Shallowford RoadLewisville, NC 27023Application for EmploymentWe consider applicants for all positions without regard to race, color, religion, creed, gender, national origin,age, disability, marital or veteran status, sexual orientation, or any other legally protected status.We desire to conduct business with the highest possible degree of safety and efficiency. If you are extendedan offer of employment, it will be contingent upon successful completion of a drug screening test, referencechecks, a physical health examination and a background investigation. Please complete and sign the attachedNotification and Release. The information provided will not be used in any way to evaluate yourqualifications for the position you are seeking.PERSONAL INFORMATIONName (Last, First, Middle):Complete all blanks. Incomplete applications will not be considered.Social Security Number__ __Address: City: State: ZIP:Home Phone: Business Phone: Other:EMPLOYMENT INFORMATIONPosition(s) Applied For:Date of Application:Work Availability:Full Time Part Time Summer Only Evenings Weekends Any ShiftDate you can start: Current Salary: Salary Desired:$ per $ perGENERAL INFORMATIONComplete all blanks. Incomplete applications will not be considered.Have you ever been employed with us before? Can you furnish proof of eligibility to work in theYes No Dates ________________________ U.S? Yes NoAre you under age 18? Yes No(If yes, you will be required to submit proof of ageand a youth employment certificate.)Are you currently employed?Yes NoDo you have a dependable means of transportation toand from work?Yes NoMay we contact your present employer?Yes No

BACKGROUND INFORMATIONGiving false or incomplete information will be considered sufficient cause for denial of employment orimmediate dismissal.Have you ever been convicted of any law violation? Yes No(If yes, list particulars. Include any plea of guilty or no contest. Include DWI/DUI violations. This will notnecessarily disqualify an applicant from employment.Do you have a valid driver’s license? Yes NoDriver’s license #: Class: State:Have you had your license suspended or revoked within the last seven years? Yes No(If yes, please explain.)EDUCATION AND SKILLSName of SchoolLocation(City and State)# of yearscompletedGraduateYes/NoType ofdegreeachievedMajor/ProgramHigh SchoolTechnical SchoolCollegeGraduate SchoolOtherAdditional job-related seminars, short courses or workshops:SPECIAL SKILLS, ADDITIONAL INFORMATIONSpecial skills or training not listed above:State any additional information you feel may be helpful to us in considering your application. Summarizespecial job-related skills & qualifications from employment or other experience.

MILITARY STATUSBranch: Dates of Service: From ToDuties:Special schools and/or specialtraining:Reserve Status: Active Inactive No Obligation NationalGuardPROFESSIONAL OR TECHNICAL CERTIFICATION/LICENSUREType of Certification:Are you registered or licensed in N.C.? Yes No If no, what state(s)?Certificate/License No.: Renewal Number: Year Obtained:Renewal Date: Has license ever been revoked or suspended? Yes NoEMPLOYMENT HISTORYAll sections must be completed. List former employers starting with current or most recent one first. Explainbreaks in employment.Present or Most Recent Employer: Type of Business: Phone:( )Address: Date Employed (month/year) Date Left (month/year)Title and duties: Full time Part timeHours per week:Supervisor’s Name and Title:Reason for leaving:Supervisor’s Phone:( )Starting Salary:$ per(hour/week/month/year)May we check reference?Yes NoFinal Salary:$ per(hour/week/month/year)Former Employer: Type of Business: Phone:( )Address: Date Employed (month/year) Date Left (month/year)Title and duties: Full time Part timeHours per week:Supervisor’s Name and Title:Reason for leaving:Supervisor’s Phone:( )Starting Salary:$ per(hour/week/month/year)May we check reference?Yes NoFinal Salary:$ per(hour/week/month/year)

Former Employer: Type of Business: Phone:( )Address: Date Employed (month/year) Date Left (month/year)Title and duties: Full time Part timeHours per week:Supervisor’s Name and Title:Reason for leaving:Supervisor’s Phone:( )Starting Salary:$ per(hour/week/month/year)May we check reference?Yes NoFinal Salary:$ per(hour/week/month/year)Former Employer: Type of Business: Phone:( )Address: Date Employed (month/year) Date Left (month/year)Title and duties: Full time Part timeHours per week:Supervisor’s Name and Title:Reason for leaving:Supervisor’s Phone:( )Starting Salary:$ per(hour/week/month/year)May we check reference?Yes NoFinal Salary:$ per(hour/week/month/year)REFERENCES – Minimum of 3. Do not list relatives.Name and title: Phone #:( )Address:Name and title: Phone #:( )Address:Name and title: Phone #:( )Address:Name and title: Phone #:( )Address:Applicant’s signatureDate:

GENERAL RELEASE AND ORDER FORMIn connection with my application for employment and/or continuing employment with you, ForsythCountry Day School, I understand that an investigative inquiry on myself will be made includingconsumer credit, criminal convictions, motor vehicle, and other reports. I understand that theseinquiries may be made at various intervals during my employment. These reports will includeinformation as to my character, work habits, performance and experience along with the reasons fortermination of past employment from previous employers. Further, I understand that you will berequesting information from various Federal, State, and other agencies that maintain recordsconcerning my past activities relating to my driving, credit, criminal, civil, education, and otherexperiences. I understand that these records will be obtained for employment purposes.Signature:_______________________________________Date:________/_______/_____________*****PLEASE PRINT CLEARLY*****Last Name______________________First Name________________Middle Name_____________OTHER Names Used:_______________________________________________________________Social Security Number:_______-________-___________ Date of Birth:________/_______/_____ADDRESS INFORMATION:Current Address:Street______________________________________City/State/Zip:____________________________Previous (include past 5 years – use reverse for additional space if necessary):Street______________________________________City/State/Zip:____________________________Street______________________________________City/State/Zip:____________________________Street______________________________________City/State/Zip:____________________________Street______________________________________City/State/Zip:____________________________SERVICES: (H/R use only – please do not write below this line)NC Statewide_______________ NC County______________ NC County Civil_________________OtherStatewide__________________ Other County____________ Other County Civil_______________Federal_________ Sex Offender ___________ Nationwide________ Credit: Employment/Tenant_

PLEASE COMPLETE IF APPLYING FOR A FACULTY POSITIONIf applying for a full or part-time faculty position, please complete the remainder of this application andreturn it along with the following credentials: (1) copy of teaching certificate (if applicable – even if it is notcurrent or held in North Carolina); (2) complete transcript(s) of all college work; (3) two letters ofrecommendation; and (4) other significant documents or publications you feel might be important in judgingyour credentials.If applying for a substitute position only, the completed application and copy of your teaching certificate (ifapplicable) are all you need to forward.Applications and credentials will be active for one year.Subject and/or Grade Level:Applying for : Full time Part time Substitute for the 20____ - 20_____ academic yearTeaching Certificate(s):State(s):Classification:Expiration Date:Certification Area(s):Language Proficiencies:Number of Semester Hours of Education Courses:Workshops or In-Service Programs in which you have participated in the last two years:School committee or administrative work in which you have participated in the last two years:Independent schools seek people accomplished in specific academic areas and in other areas of school life.Please indicate those areas where you would be willing to serve. Mark (1) where you have great proficiency orexperience, and (2) where you could assist._____Newspaper _____Debate/Model UN _____Athletics (specify)_____Literary Magazine _____Language Clubs ____________________________Yearbook _____Science Clubs ____________________________Photography _____Outdoor Education _____Other (specify)_____Dramatics _____Student Government _____________________________Public Speaking _____Service Organizations ________________________

TEACHING EXPERIENCEName of School:City, State:Supervisor’s Name:From:Month/yearReason for leaving:Until:Month/yearGrades/Subjects taught:Other duties:Name of School:City, State:Supervisor’s Name:From:Month/yearReason for leaving:Until:Month/yearGrades/Subjects taught:Other duties:Name of School:City, State:Supervisor’s Name:From:Month/yearReason for leaving:Until:Month/yearGrades/Subjects taught:Other duties:Name of School:City, State:Supervisor’s Name:From:Month/yearReason for leaving:Until:Month/yearGrades/Subjects taught:Other duties:Please attach a sheet for any additional experience. If reason for leaving was health related, you need notprovide specific information.

EDUCATION PHILOSOPHYIn paragraph form, please answer the question, “How do you know when a child has learned?”Applicant’s signatureDate:

FORSYTH COUNTRY DAY SCHOOLSUPPLEMENTAL PERSONAL DATA for EVALUATING AFFIRMATIVEACTION RECRUITMENTDisclosure of this information is voluntary and will be used only for legally required reporting purposesand in furtherance of equal employment opportunity. The information provided will not be used in any wayto evaluate your qualifications for the position you are seeking.Name: ______________________________________________________________________________Position Applied For: ______________________________ Date of Application: _____________Please check the information appropriate to you:1. Predominant Racial/Ethnic BackgroundWhite, not of Hispanic origin. Persons having origins in any of the original peoples of Europe, NorthAfrica, or the Middle East.Black, not of Hispanic origin. Persons having origins in any of the Black racial groups of Africa.Hispanic. Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanishculture or origin, regardless of race.American Indian or Alaskan Native. Persons having origins in any of the original peoples of NorthAmerica, who maintain cultural identification through tribal affiliation or community recognition.Asian or Pacific Islander. Persons having origins in any of the original peoples of the Far East,Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China,Japan, Korea, the Philippine Islands and Samoa.2. Veteran StatusVietnam Era Veteran with more than 180 days of active military service, and part of which wasbetween August 5, 1964 and May 17, 1975, with a discharge other that dishonorable or released for aservice-related disability during the same period.Disabled veteran with a disability of 30 percent or more administered by the VA, or discharged orreleased from active military service for disability.3. Gender Female Male4. Do you have a disability as defined by the Americans with Disabilities Act? Yes No5. Source of Vacancy InformationAdvertising – What source? ___________________________________________________________________Word of mouth – From FCDS Employee Other (specify) _________________________________If none of the above, please specify______________________________________________________________