PONTOTOC TECHNOLOGY CENTER 601 West 33rd Ada OK 74820 (580) 310-2200 "Training to Succeed" Application for Employment Assistance in completing this form is available. Please ask the person who gave you this form, if you need assistance. Federal and state laws prohibit discrimination in employment practices on account of race, creed, color, national origin, ancestry, sex, age, marital status, veteran status, or disability. This policy does not apply to part-time Adult Training and Development instructors, Business and Industry Services instructors, substi- tute teachers, or bus drivers. Classification of Positions: * Administration * Professional * Instructional Certified Non-Certified * Support Clerical Custodial Instructional Assistant * Other Part-Time Date of Application _ First Name Middle Initial Last Name City State Zip Code Address Telephone (Home) (Work) When are you available for employment? _ Acceptable minimum salary? _ Have you worked under another name? If yes, please explain _ YES NO Are you over 18 years old? YES NO Are you prevented from lawfully becoming employed in this country because of visa or immigration status? YES NO Proof of citizenship or immigration status will be required upon employment.
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PONTOTOC TECHNOLOGY CENTER601 West 33rdAda OK 74820(580) 310-2200
"Training to Succeed"Application for Employment
Assistance in completing this form is available. Please ask the person who gave you this form, if you need assistance.
Federal and state laws prohibit discrimination in employment practices on account of race, creed, color, national origin, ancestry, sex,age, marital status, veteran status, or disability.
This policy does not apply to part-time Adult Training and Development instructors, Business and Industry Services instructors, substi-tute teachers, or bus drivers.
Classification of Positions:* Administration
* Professional
* InstructionalCertifiedNon-Certified
* SupportClericalCustodialInstructional Assistant
* Other Part-Time
Date of Application _
First Name Middle InitialLast Name
City State Zip CodeAddress
Telephone (Home) (Work)
When are you available for employment? _
Acceptable minimum salary? _
Have you worked under another name?
If yes, please explain _
YES NO
Are you over 18 years old? YES NO
Are you prevented from lawfully becoming employed in this country because
of visa or immigration status? YES NOProof of citizenship or immigration status will be required upon employment.
/
Have you ever been convicted of a felony or a misdemeanor which resulted in imprisonment?
YES NO
Ifyes,pleaseexpl~n~~~~~~~~~~~~~~~~~~~~~~~~~~~~~A conviction will not necessarily disqualify an applicant from employment. A request for a background check will be made upon employment.
Answer these questions only after reviewing a descriptionof the job for which you are applying.
Do you have any outside commitments that will or could interfere with you doing your job?
YES NO
Ifyes,pleaseexpl~n~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Are you capable of performing in a reasonable manner the activities involved in the job or occupa-tion for which you have applied? (A description of the act'ivities involved n such ajob or occupation is attached.)
YES NO
For Teaching Positions OnlySummary of Employment Experience
1. Total years of experience as a teacher or school administrator _~~~~~_
2. Total years of experience in business, industry, agriculture, or military service related to yourarea of specialization ~~~~~~~
3. Total years of military service ~~~~~~_
Teacher Certification and Licensing
Do you presently hold any type of teaching or administrative certification in Oklahoma?
YES NO
If yes, attach a copy of your Oklahoma Teaching Certificate to the application.
If you do not qualify for a Standard Teaching Certificate in Oklahoma, are you willing to worktoward completion of the minimum requirements for your area of specialization? YES NO
Are you licensed or certified by any trade or profession? YES NO
Indicate kind of license or certificate -~~~~~~~~~~~~~~~~~~~~~~---
Note: Specific information regarding teaching certification may be obtained by writing to:
Career Tech Teacher CertificationOklahoma Department of Career and Technology Education
1500 West Seventh AvenueStillwater, OK 74074
(405) 377-2000
!
EMPLOYMENT EXPERIENCE(Required for all positions)
List each position held, with your present or most recent position first; include military experience. Continue on aseparate sheet of paper if you need additional space.
Dates Employed Name and Address of Employer Summary of Work Performed
From: Mo. YearTo: Mo. Year
Job Title: Supervisor: Reason for Leaving:
Dates Employed Name and Address of Employer Summary of Work Performed
From: Mo. YearTo: Mo. Year
Job Title: Supervisor: Reason for Leaving:
Dates Employed Name and Address of Employer Summary of Work Performed
From: Mo. YearTo: Mo. Year
Job Title: Supervisor: Reason for Leaving:
Dates Employed Name and Address of Employer Summary of Work Performed
From: Mo. YearTo: Mo. Year
Job Title: Supervisor: Reason for Leaving:
Dates Employed Name and Address of Employer Summary of Work Performed
From: Mo. YearTo: Mo. Year
Job Title: Supervisor: Reason for Leaving:
Please include a current resumewith your completed application.
/
EDUCATION(Required for all positions)
School Name and Location of School Course of Study No. of Years Did You Degree, Di-or MajorlMinor or Credit Graduate or ploma, or
Hours Com- Complete Certificatepleted Training? Received
High School YES(Year )
NO
College/ YESCareer Tech Center (Year )
NO
Other YES(Year )
NO
NOTICE: A post employment physical may be required. Arrangements for the examination will be made byPontotoc Technology Center at the school's expense. Results of the Physical examination will be confidential.
AGREEMENT
I have read and understand the notice regarding a post employment physical examination. I certify that an-swers given herein are true and complete to the best of my knowledge. I understand completion of this appli-cation does not constitute an offer of employment. In the event of employment, I understand that false or mis-leading information given in my application or interview(s) may result in discharge. I further understand thatupon employment, I am required to abide by all laws, policies, rules, and regulations of the Board of Educa-tion and Administration of Pontotoc Technology Center, District #14, the Oklahoma Department of Careerand Technology Education, and the State of Oklahoma.
Signature _ Date ----------------------------
Social Security Number:
NON-DISCRIMINATION STATEMENT:Pontotoc TechnologyCenter, in compliance with Title VIof the Civil Rights Act of 1964, section 504 of theRehabilitation Act of 1973, the Americans withDisabilities Act of 1990 and Title IX of the EducationAmendment of 1972, does not discriminate on the basisof race, ethnicity, religion, national origin, age, gender,disability or veteran status in any of its policies,practicesor procedures. These equal opportunity provisionsinclude, but are not limited to admissions, employment,financial aid and student services.
