NEWBURY LOCAL

SCHOOL DISTRICT

14775 Auburn Road · Newbury, OH 44065-9745 Application for Classified Position

Date of Application ____________

Personal Data

Name (last, first, middle) Soc. Sec. #

Present Address Phone No.

Permanent Address Phone No.

Are you a U.S. Citizen? Yes c No c If not, do you intend to become a citizen? Yes c No c

Have you ever been convicted of or pleaded guilty to any felony, any violation of

R.C. 2907.04 or 2907.06, or division (A) or (C) of R.C. 2907.07, any offense of violence,

theft offense (as defined in R.C. 2913.01), drug abuse offense (as defined in R.C. 2925.01)

which is not a minor misdemeanor, or any misdemeanor sex offense? Yes c No c

Position Information

Position(s) for which you are applying Full time ___________ Part time ______________

Reason(s) you are applying

Salary Desired Date you can start work

Do you have the ability to perform all essential functions of this

Position with or without a reasonable accommodation? Yes c No c

Referred by:

Names of friends or relatives employed by this district:

List qualifications you have for the position desired:

Work Experience

Inclusive Reason for

Employer Position Dates Salary Leaving

Education

Name of School From/To Subject

Grade School Not Applicable

High School

Advanced Training

References

List at least three (3) persons who have known you at school or work

Name Address School or Work

Do we have permission to contact the above-named persons? Yes ____________ No ___________

I hereby certify that answers on this application are true and correct to the best of my knowledge and belief, and that any deliberate misrepresentation of fact contained herein may be grounds for invalidating my contract commitments resulting from this application. I understand that my employment will be subject to the laws of the State of Ohio and to the job descriptions and policies adopted by the Newbury Local Board of Education.

________________________________________________________ ____________________________

Signature Date

The Newbury Local School District Board of Education does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment, or the provision of services.

NOTE: Unless reactivated by written request, this application will be destroyed 2 years from date of filing.