Lincoln County School District #2 222 E. 4th Avenue P.O.

Box 219 Afton, WY 83110 (307) 885-3811 ♦ Fax (307) 885-9562 ♦ www.lcsd2.org

CLASSIFIED EMPLOYEE APPLICATION

Last Name/ First/ Middle Present Address City/State/Zip

Date E-mail Address Home Phone Mobile Phone

Position applied for EDUCATION Name of High School & Location Circle Year Completed 9 10 11 12

Date available for work

College/University & Area of Study Circle Year Completed 1 2 3 4

EMPLOYMENT EXPERIENCE Please list all experience of three months or longer. Begin with the most recent. Attach an extra sheet if needed. Name of Business & Location Dates Inclusive Position Reason for Leaving

MAY WE CONTACT YOUR PRESENT EMPLOYER? YES

NO

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REFERENCES Please list three to five persons who can answer questions concerning your qualifications for the position you seek. Include supervisors under whom you have worked. The district reserves the right to contact persons not specified by you. Submission of an application to the district constitutes your permission and consent for the district to contact any person(s) and discuss you, your qualifications, and other pertinent matters. Name/Title Relationship Address Telephone Number

Pursuant to the provisions of W.S. 21-7-401, any employee who is to be hired by the school board on or after July 1, 1996, who may have access to minors is required to submit to fingerprinting and to provide any other information as is necessary to acquire a national criminal history background check. Are you willing to submit to the necessary criminal and history background checks? Yes No Conviction of a crime is not an automatic bar to employment. The district will consider the nature of the offense, the date of the offense, and the relationship between the offense and the position for which you are applying. 1. Have you ever been involuntarily terminated or asked to resign from any job? 2. Have you ever been convicted of an offense other than a minor traffic violation? (DUI and DWI convictions are not considered minor and must be reported.) 3. Have you ever been arrested for a felony? (Even if no contest or charges dropped or pled down.) 4. Have you ever been charged with a felony? (Even if no contest or charges dropped or pled down.) 5. Have you ever been convicted of a felony? (Even if no contest or charges dropped or pled down.) 6. Have you ever been arrested for a sex-related offense? (Even if no contest or charges dropped or pled down.) 7. Have you ever been charged with a sex-related offense? (Even if no contest or charges dropped or pled down.) 8. Have you ever been convicted of a sex-related offense? (Even if no contest or charges dropped or pled down.) 9. Have you ever been arrested for a drug-related offense? (Even if no contest or charges dropped or pled down.) Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No

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10. Have you ever been charged of a drug-related offense? (Even if no contest or charges dropped or pled down.) 11. Have you ever been convicted of a drug-related offense? (Even if no contest or charges dropped or pled down.) 12. Have you ever been arrested for an act of violence, including domestic violence? 13. Have you ever been charged for an act of violence, including domestic violence? 14. Have you ever been convicted for an act of violence, including domestic violence? 15. Are you prevented from being lawfully employed in this country because of visa or immigration status? Proof of status will be required if employed.

Yes Yes Yes Yes Yes Yes

No No No No No No

If you answered yes to any of the above questions, and/or have any pending charges, as well as pleas of nolo contendre, please attach explanation on a separate sheet. 1. Please describe any professional or community activities, knowledge or skills you have which you think would be helpful in this position.

I authorize Lincoln County School District #2 to obtain information about any criminal records I may have. I also authorize all governmental agencies to provide information to Lincoln County School District #2 about any criminal record I may have. I verify that all information on this employment application is true and complete. I understand that any misrepresentation, falsification, or omission on this application or other documents submitted to Lincoln County School District #2 will be sufficient cause for this application not to be considered by the School District or for dismissal if I have been employed. I authorize Lincoln County School District #2 to check my references, to obtain information from my prior employers and educational institutions, and to take other actions to investigate any information provided in my application employment, and to obtain information relevant to evaluating my qualifications and fitness for a teaching position. I authorize the release of any and all information or records maintained by the Wyoming Department of Family Services. I authorize my listed references, past employers and educational institutions, and anyone else who has information about my work history, education, qualifications, or fitness, to provide such information to Lincoln County School District #2. I release Lincoln County School District #2 and all persons providing information to the school district from any liability whatsoever for obtaining and providing that information. A photocopy of this release shall be as effective as the original. Signature Date

Applicants for admission and employment, students, parents, persons with disabilities, employees, and all unions or professional organizations holding collective bargaining or professional agreements with Lincoln County School District #2 are hereby notified that this school district does not discriminate on the basis of race, sex, color, national origin, age, religion, or disability, in admission or access to, or treatment or employment in, its programs and activities. Any person having inquiries concerning the school’s compliance with the regulations implementing Title VI, Title IX, The Americans with Disabilities Act (ADA) or Section 504 is directed to contact the following individual who has been designated to coordinate efforts to comply with the regulations regarding nondiscrimination- Mark Taylor, PO Box 219, 222 E. 4th Avenue, Afton, WY 83110, (307) 885-3811. TTY- 1-800-877-9965

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