Office Use Only
____    BCI  Date ____________
____    FBI   Date ____________

____    Current Educ. Aide Cert,
____    Current Pupil Activity Cert.
____     References

Copy:	_____	Maintenance            
                  _____	Food Service            
	_____	Transportation 
	_____	Bldg. Administrator     	_____        ________________

CLOVERLEAF LOCAL SCHOOL DISTRICT
8525 Friendsville Road         Lodi, OH 44254

CLASSIFIED/SUPPLEMENTAL
Employment Application
_________________
Today’s Date ______________

Personal Information (please print clearly or type)

	NAME ______________________________________________________________________
		Last                                                                First                                             Middle

	ADDRESS	 ________________________________________________________________
			 Street                                                                           Apt. #

			________________________________________________________________
			City                                                     State                                              Zip Code

	MAILING ADDRESS (if different) _______________________________________________
						P.O. Box

			________________________________________________________________
			City                                                     State                                             Zip Code

	CONTACT INFORMATION

		_________________________________        _________________________________
			Daytime Phone Number			Evening Phone Number

		_________________________________ 	__________________________________
			Cell Phone Number				E-Mail Address
	
Position(s) Applying For:

	_____Educational Aide		_____*HQ Educational Aide	
					(* 2 years college, Associates Degree, or Paraprofessional Certification)

	_____Secretary			_____Cafeteria Helper	_____Custodian				
_____Bus Driver			_____Other
		
Supplemental Position   _________________________________________________________
					      			(description)

	Full Time _____	Part Time _____	Sub List _____	Supplemental ______

Employment History

Please list your employers from most recent to least recent
1.
Current Employer		
Address		
Supervisor Name		
Phone Number		
Dates of Employment		
Job Title and Duties		
Salary		
Reason for Leaving		
May we contact your current employer?    ____  yes             ____ no
2.
Employer Name		
Address		
Supervisor Name		
Phone Number		
Dates of Employment		
Job Title and Duties		
Salary		
Reason for Leaving		

3.
Employer Name		
Address		
Supervisor Name		
Phone Number		
Dates of Employment		
Job Title and Duties		
Salary		
Reason for Leaving		

Please list additional employers on a separate sheet and attach it to this application.

Education History

Name & Address of School	Date(s) of Attendance	Did you Graduate?	Degree Earned	

				

Please answer the following questions.

Failure to be truthful in these answers is grounds for dismissal.  If you answer YES to any of the following questions, please explain your answer in the space provided, or on a separate sheet of paper and submit it with this application.

1.	Have you ever resigned from, or otherwise left, public employment to avoid investigation for alleged misconduct or dismissal in Ohio, or any other State?

_____ Yes		_____ No

2.	Have you ever been employed by the Cloverleaf Local School District Board of Education?
_____ Yes		_____ No

3.	Have you ever been dismissed from any probationary employment?
_____ Yes		_____ No

4.	Have you ever served in the United States Armed Services?   (If so, please describe in detail below, or on a separate page.)
_____ Yes		_____ No

5.	Are you legally eligible to work in the United States?	
_____ Yes		_____ No

Explanation(s) ______________________________________________________________________

Please list and describe any special skills, licenses, or other qualities which qualify you for employment with the Cloverleaf Local School District Board of Education.

Please list three references (do not include relatives)

Name	Occupation	Address	Phone Number	Relationship to 
Applicant	
1.					
2.					
3.					

PLEASE READ THIS SECTION CAREFULLY AND SIGN YOUR NAME INDICATING YOUR UNDERSTANDING.

1.	Pursuant to Ohio Revised Code 3319.39, I understand that anyone under final consideration for employment by a Board of Education must obtain a criminal background check from the Bureau of Criminal Identification.  The cost of this records check is payable by the applicant.  Please contact Cloverleaf Superintendent’s Office for further information.

2.	I understand that the Board of Education or its agents have the right to investigate the information in this application.  Failure to be truthful on this application is grounds for dismissal.

3.	Cloverleaf Local School District does not discriminate against individuals because of race, sex, national origin, age or disability.  Ohio Revised Code 4112.02(A).

4.	This application is in effect for 12 months.  If you wish to remain on the active list, you MUST notify the superintendent’s office of your availability prior to the expiration date.

Applicant Signature __________________________________________________________________

Date ___________________________