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 #: ___________________________________              

                                                                                                                      Date of Birth: ___________________________________  

 

Name: _____________________________________________________________________________________________

                                last                                                       first                                                      middle

 

Address: __________________________________________________________________________________________

                                Number                                Street                                                  City                       State                    Zip

 

Telephone:            Home:                                                                                     Cell:                                                                                       

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised  7/09

Emergency contact:

                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.

 

 

 

RACE/ETHNICITY INFORMATION:    (Please complete the information below in both boxes)

Federal guidelines require that we gather race/ethnicity information on all new employees in a two part question.

 

WHAT IS YOUR ETHNICITY?                                             Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican,

                                                                                                     South or Central American, or other Spanish culture or origin, regardless of race)

        (must check one)                                                                                                        

                                                                                                     NOT Hispanic or Latino                                                                          

 

 

WHAT IS YOUR RACE? (you may check up to five)

The above part of the question is about ethnicity, not race.  No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race(s) to be:

  American Indian or Alaskan Native                       Laotian                                           Tahitian

(Persons having origins in any of the original               Cambodian                                     Other Pacific Islander

people of North, Central or South America)                 Hmong                                            Filipino/Filipino American

  Chinese                                                                   Other Asian                                    African American or Black

  Japanese                                                                 Hawaiian                                         White  (Persons having origins

  Korean                                                                    Guamanian                                      in any of the original peoples of

  Vietnamese                                                             Samoan                                           Europe, North Africa, Northwestern

  Asian Indian                                                                                                                        Asia or the Middle East)

 

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

 

                                                                                                                                                                                                                               

                Signature of Applicant                                                                                        Date