Westbrook School Department 117 Stroudwater Street Westbrook, Maine 04092 (207) 854-0800 FAX (207) 854-0809 [email protected] APPLICATION FOR ADMINISTRATIVE POSITION

THE WESTBROOK SCHOOL DEPARTMENT DOES NOT DISCRIMINATE IN THE OPERATION OF ITS EDUCATIONAL AND EMPLOYMENT POLICIES AND WILL HONOR ALL APPROPRIATE LAWS RELATIVE TO DISCRIMINATION.

Date __________________________________

Position(s) applying for:

Name _________________________________

____________________________________________

When will you be available? _______________

____________________________________________

Email Address

____________________________________________

Permanent Address ____________________________________________________

Phone ___________________

Temporary Address ____________________________________________________

Phone ___________________

EDUCATION: Transcripts, including grades, from all college(s)/university(ties) attended must be provided. It is essential that this section be completed accurately. Number of Location Degree Years Completed College/University Attended ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ EXPERIENCE: A resume must be provided. In addition to educational background and work experience, include extracurricular activities in which you have been involved. Please list below positions held, employer and dates of employment for the past ten years beginning with your most current or recent experience. Please account for any gaps in employment on a separate page. No. of Years

Dates From/To

Position

Employer Name, Address & Telephone No.

____________________________________________________ _____________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Other relevant work experience and achievements:

2014-2015 jb

One Promise: The best education for all for life.

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________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

CERTIFICATION: List certification(s) you hold and provide copies of certification. State Date Issued Date of Expiration Type ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ If you do not hold a Maine certificate, for what type of Maine certificate are you applying and eligible? ____________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ NOTE:

Candidates who do not hold Maine certification should direct an inquiry to the Maine Department of Education, Certification Office, Augusta, Maine 04333.

BACKGROUND Have you ever been disciplined, discharged, or asked to resign from a prior position?

Yes____No____

Have you ever resigned from a prior position after a complaint had been received against you or your conduct was under investigation or review?

Yes____No____

Has your contract in a prior position ever been non-renewed?

Yes____No____

Have you ever not been nominated for re-employment in a prior position or ever had your nomination for re-employment not be approved?

Yes____No____

Have you ever been charged with or investigated for sexual abuse or harassment of another person?

Yes____No____

Have you ever been convicted of a crime (other than a minor traffic offense)?

Yes____No____

Have you ever entered a plea of guilty or “no contest” (nolo contendere) to any crime (other than a minor traffic offense)?

Yes____No____

Have you ever had a professional license or certificate suspended or revoked in any state, or have you ever voluntarily surrendered, temporarily or permanently, a professional license or certificate in any state? Yes____No____ Has any court ever deferred, filed or dismissed proceedings without a finding of guilty and required that you pay a fine, penalty or court costs and/or imposed a requirement as to your behavior or conduct for a period of time in connection with any crime (other than a minor traffic offense)?

Yes____No____

If you have answered YES to any of the previous questions, provide full details on an additional sheet, including, with respect to court actions, the date, offense in question and the address of the court involved. Conviction or other disposition of a crime is not necessarily an automatic bar to employment.

One Promise: The best education for all for life.

Page 2/3

REFERENCES: List three, two of whom are most recent supervisors, who can comment on your ability and whom we may contact. In addition, please provide three current letters of reference from persons who are not related to you (may be from references listed below). Position Address Phone Name ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ My signature below constitutes authorization to check my employment history, including without limitation, criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any state, local or federal agency. I further authorize those persons, agencies or entities that the Westbrook School Department contacts in connection with my employment application to fully provide the Westbrook School Department any information on the matters set forth above. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the Westbrook School Department its agents and officials or against any provider of such information. I understand that information submitted in and with this application may be disclosed to a screening and/or interviewing committee, which may include board members, administrators, staff, and members of the community. I give my consent to this disclosure. _______________________________________ Signature/Date I hereby give permission to contact the employers and references listed above concerning my prior work experience.

_______________________________________ Signature/Date Please indicate if there is a particular employer you do not want us to contact. __________________________ ___________________________________________________________________________________________

APPLICATION FOR ADMINISTRATIVE POSITION CHECK LIST: The completed employment application cannot be evaluated unless all of the following materials have been provided: _____ _____ _____ _____ _____ _____ _____ _____

Application form fully completed Copies of Transcript(s) Copy of Maine Certification(s) Resume Gaps in employment during the past ten years explained YES to any of the questions in the Background section explained Three current letters of reference Application signed

NOTE: ALL APPLICATION MATERIALS BECOME THE PROPERTY OF THE WESTBROOK SCHOOL DEPARTMENT. NONE WILL BE RETURNED. PROVIDING ANY FALSE OR MISLEADING INFORMATION ON THIS APPLICATION OR IN THE APPLICATION OR EMPLOYMENT SCREENING PROCESS SHALL BE FULLY SUFFICIENT GROUNDS TO REFUSE TO EMPLOY THE APPLICANT OR, IF THE APPLICANT HAS BEEN EMPLOYED, TO IMMEDIATELY DISMISS THE APPLICANT/EMPLOYEE. NOTE: EMPLOYMENT CANNOT BE FINALIZED UNTIL THE APPLICANT HAS COMPLETED REQUIREMENTS FOR COMPLETE BACKGROUND CHECKS AND FINGERPRINTING AS REQUIRED BY MAINE STATE STATUTE. NOTE: IN COMPLIANCE WITH THE IMMIGRATION REFORM AND CONTROL ACT OF 1986, EACH NEW EMPLOYEE, AS A CONDITION OF EMPLOYMENT, MUST COMPLETE THE EMPLOYMENT ELIGIBILITY VERIFICATION FORM I-9 AND PRESENT DOCUMENTATION ESTABLISHING IDENTITY AND EMPLOYMENT ELIGIBILITY. One Promise: The best education for all for life.

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