Transportation Employment Application

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District 5 Transportation Employment Application

Name*
Enter at least 3 responses.

Last Name
First Name
Middle / Maiden Name

Address*
Enter at least 4 responses.

Street Address
City
State
Zip Code

3.	Social Security Number*

4.	Date of Birth*
	mm/dd/yyyy

Drivers License*
Enter at least 4 responses.

Drivers License Number
Drivers License State Issued
Drivers License Class
Driver License Expiration Date

6.	Home Phone Number*

7.	Cell Phone Number*

Citizenship *Must be a US citizen or authorized alien.*

A citizen or national of the United States

A Lawful Permanent Resident

9.	If you checked "A Lawful Permanent Resident" to the previous question please list your Alien Number below.

10.

Education*
Enter at least 2 responses.

Name and Address of High School Attended
Year Graduated *(Must be a High School Graduate or equivalent and provide copy of Diploma or GED certification.)

11.

Previous Employment (Must list any previous employment with School District Five).

Have you ever been employed with School District Five?
If "Yes" what was your position within the District?
What were your dates of employment with the District?

Background Information - This information will be kept confidential. Any falsification or deliberate misrepresentation, including omission of a material fact or failure to complete any part of your application or this questionnaire can be grounds for denial of employment or termination from employment with District Five. All questions must be answered regardless of city, state or country where the offense, occurred including those outside of the United States or regardless of whether the charge has been dropped, dismissed, expunged or not prosecuted.

12.	Background Information - Have you ever been charged or convicted of any dependency action to have sexually assaulted or exploited any minor or to have physically abused any minor? *
	Background Information - Have you ever been charged or convicted of any dependency action to have sexually assaulted or exploited any minor or to have physically abused any minor? * YesNo

13.	Background Information - Have you ever been charged or convicted of a domestic relations proceeding, to have sexually abused or exploited any minor or to have physically abused any minor?*
	Background Information - Have you ever been charged or convicted of a domestic relations proceeding, to have sexually abused or exploited any minor or to have physically abused any minor?* YesNo

14.	Background Information - Have you ever been charged or convicted of any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person?*
	Background Information - Have you ever been charged or convicted of any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person?* YesNo

15.	Background Information - Have you been charged or convicted or been released from prison for any offense that involved drugs, embezzlement or fraud?*
	Background Information - Have you been charged or convicted or been released from prison for any offense that involved drugs, embezzlement or fraud?* YesNo

16.	Background Information - Have you ever been arrested, charged, or convicted of any other offense, other then minor traffic violations, regardless if charge has been expunged, dismissed, not prosecuted or even if you have been convicted. If yes, you will be asked to explain after the next set of questions.*
	Background Information - Have you ever been arrested, charged, or convicted of any other offense, other then minor traffic violations, regardless if charge has been expunged, dismissed, not prosecuted or even if you have been convicted. If yes, you will be asked to explain after the next set of questions.* YesNo

17.

Have you ever been arrested, charged or convicted of any of the following crimes against person(s):*

	Yes	No
Selling or Distributing Erotic Material or Pornography
Malicious Harassment
Child Molestation
Kidnapping
Child Buying or Selling
Sexual Misconduct
Prostitution
Manslaughter
Robbery, Burglary or Theft
Vehicular homicide
Driving While Intoxicated or Driving While Impaired
First, Second or Third Degree Rape
Rape of a Child
Assault of a Child
Incest
Child Abuse or Neglect
Indecent Liberties or Exposure
Child Abandonment
Assault
Any Criminal Mistreatment
Murder
Careless or Reckless Driving

18.	If your answer is "yes" to any of the questions above, please describe details and provide the date(s) of the conviction(s) and the sentence(s) imposed below *Must provide description, date(s) location, charge, conviction(s) and the disposition of each arrest, charge or conviction. Applicants who have lived outside of South Carolina must provide a Department of Motor Vehicle and State Background check from the state they resided in during the last 10 years.

Medical Background - This information will be kept confidential. Any falsification or deliberate misrepresentation, including omission of a material fact or failure to complete any part of your application or this questionnaire can be grounds for denial of employment or termination from employment with District Five. All questions must be answered. If additional space is needed, attach a separate sheet of paper.

19.

Do you currently have; been previously diagnosed with; been recommended for treatment of; or take any medication for any of the following:*

	Yes	No
Seizures, convulsions and/or epilepsy
Diabetes or sugar in urine
Diabetes requiring pills or insulin
High Blood Pressure
Fainting
Anxiety or mental illness
Back Pain (Chronic or disabling)
Depression
Any infectious disease
Kidney Disease or dialysis
Spinal Injury or Disease
Eye disorder or impaired vision
Digestive problems
Chronic Fatigue
Sleep apnea or sleeping disease
Narcolepsy
Snoring, daytime sleepiness
Chest Pain
Asthma
Amputations
Tuberculosis or a positive TB test
Heart Attack
Palpitations
Arthritis
Nervous condition(s)
Hearing loss or loss of balance
Muscular Disease
Liver Disease

20.	If you answered "Yes" to any of the above, please describe and provide the date(s) of illness or injury on the next page.

21.

Current Medications - Must list all current medications taking regardless if over the counter or prescribed - use a separate piece of paper if necessary.

Name of Medication
Taken For
Dosage
Name of Medication
Taken For
Dosage
Name of Medication
Taken For
Dosage
Name of Medication
Taken For
Dosage

22.

Work Experience*

	Yes	No
Have you ever been dismissed, discharged, or fired from any employment?
Have you ever resigned from or otherwise left any employment while allegations of misconduct on your part were pending or under investigation?
Have you ever been disciplined by a past or present employer because of allegations of misconduct?
Are you currently the subject of any investigation or inquiry by an employer because of allegations of misconduct or harassment on your part or have you ever been found to be guilty of misconduct or harassment by an employer?

23.

Employment History - Must list all periods of employment for the last 10 years, use additional paper if necessary.*
Enter at least 9 responses.

Name of Employer
Address
City
State
Supervisor's Name
Your Job Title or Position
Telephone Number
Worked From (MM/YY)
Worked Until (MM/YY)

24.

Employment History Continued

Name of Employer
Address
City
State
Supervisor's Name
Your Job Title or Position
Telephone Number
Worked From (MM/YY)
Worked Until (MM/YY)

25.

Employment History Continued

Name of Employer
Address
City
State
Supervisor's Name
Your Job Title or Position
Telephone Number
Worked From (MM/YY)
Worked Until (MM/YY)

26.	Explanation of Work Experience - Must provide explanation of discharge, termination.* Note: Applicants who have received five (5) traffic violations and/or three (3) at fault accidents within the last ten (10) years may not be considered for training or employment.

27.

Personal Contacts 1 - You must list at least three personal contacts other than employers and family members - these references may be contacted.*
Enter at least 8 responses.

Name
Address
City
State
Relationship
Phone Number
Known From (MM/YY)
To (MM/YY)

28.

Personal Contacts 2*
Enter at least 8 responses.

Name
Address
City
State
Relationship
Phone Number
Known From (MM/YY)
To (MM/YY)

29.

Personal Contacts 3*
Enter at least 8 responses.

Name
Address
City
State
Relationship
Phone Number
Known From (MM/YY)
To (MM/YY)

30.

Disclaimer - Must be read and signed.*
The information within this application must be correct and complete. The applicant must understands that any false statement(s), misrepresentation or omission of information on this application or other required documents shall be considered sufficient cause for denial of employment or dismissal at any time regardless of when statement, misrepresentation or omission was made. AUTHORIZATION is hereby given to the school district to investigate medical records, records with prior employers, schools, police, law enforcement agencies, FBI and driving record now or at any time during employment. Applicant also consents to be tested for drugs and for alcohol at the discretion of the school district and understands that a positive test result or refusal to be tested will be cause for dismissal. UNDER PENALTY OF PERJURY, I certify that the above information is true, correct and complete. I understand that if I am hired, I can be discharged for any misrepresentation or omission in the above statement. I understand that if I am hired, my employment is conditional based on your receipt of a satisfactory report(s) from any or all law enforcement agencies or other sources. I also understand that I may be dismissal from employment if, at any time, information on this application is found to be false, misleading or in any way a misrepresentation of the facts or of the information I have provided. I hereby release all sources from any and all liability. My electronic signature below certifies that the above information is true, correct and complete.
Enter at least 2 responses.

Name
Date