Application for Employment - Stallworth Charter Schools

*Are you at least 18 years of age? Yes No

*Do you have a valid Driver's License? Yes No

If not citizen, do you have legal right to remain in the U.S.? Yes No

*Do you have the legal right to work in the U.S.? Yes No

*Are you employed now? Yes No

*If so, may we contact your employer? Yes No

Education

High School Graduate? Yes No

College Graduate? Yes No

Trade School Graduate? Yes No

Employment Desired

Are you applying for Non-Teaching Staff/Full-Time Teaching Staff Temporary or Part-Time

Do you have a reliable means of transportation to and from work? Yes No

*Can you present proof of US citizenship/right to work? Yes No

Essential Functions Are you able to perform the essential functions of the job for which you are applying either with or without reasonable accommodation?

Please select yes/no to answer the essential functions question. Yes No

Have you ever applied or worked for DLDSSCSI before? Yes No

Do you have any friends or relatives working for DLDSSCSI? Yes No

Are you related to anyone working for the Stockton USD? Yes No

Have you ever been investigated by any school districts? Yes No

*Convicted of a criminal office, felony, or misdemeanor? Yes No

Criminal Offense, Felony, or Misdemeanor If yes, state below the nature of the crime(s), when and where convicted, and the disposition of the case. A criminal clearance is required for any employee who has contact with our students. We will do a background check and Live Scan fingerprinting on all prospective employees. (Conviction of a criminal offense will not necessarily bar you from employment here. By law, your fingerprints must be submitted to the Federal Bureau of Investigation. If you disclose offenses on this application form, special consideration can be given to their nature and circumstances. Failure to make full disclosure will cause DLDSSCSI to require your immediate termination of employment).

Employment History

List all employment of the past five years, starting with the most recent. Please complete the following section even if attaching a resume.

Employment Section #1

May we contact your employer? Yes No

Employment Section #2

May we contact your employer? Yes No

Employment Section #3

May we contact your employer? Yes No

References

Please provide the names of three persons not related to you whom you have known for a minimum of one year, and be sure to include phone numbers.

Withholding Information Certification 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 facts 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.

Authorize Investigation I hereby authorize investigation of all statements and records contained in this application and I authorize all references I have listed to disclose to DLDSSCSI any and all information related to my work records without giving me prior notice of such disclosure. In addition, I hereby release DLDSSCSI, my former employers and all other persons, corporations, partnerships, and associations from any and all claims arising out of or in any way related to such investigation or disclosure.

At-Will Employment Further, I understand and agree that my employment is at-will and for no definite period and may be terminated at any time without previous notice at the option of Dr. Lewis D. Stallworth, Sr. Charter School or myself, and that no promises or representation contrary to the foregoing are binding on DLDSSCSI unless made in writing and signed by me and the agency's representative. I agree to abide by the rules the DLDSSCSI set forth in the Policies and Staff Manual. I agree to submit to an authenticated fingerprint card, evidence of good health, T.B. test result before reporting for work.