WEST HARRISON COMMUNITY SCHOOL DISTRICT 410 PINE ST MONDAMIN, IOWA 51557 DISCRIMINATION POLICY STATEMENT: It is the policy of the West Harrison Community School District not to illegally discriminate on the basis of race, color, national origin, sex, disability, religion, creed, age(for employment), marital status (for programs), sexual orientation, gender identity and socioeconomic status (for programs) in its educational programs and its employment practices. There is a grievance procedure for processing complaints of discrimination. If you have questions or a grievance related to this policy please contact the district’s Equity Coordinator, Lyle Schwartz, Superintendent, 410 Pine Street, Mondamin, Iowa 51557 712-646-2231 [email protected]

NAME______________________________________________________________________________________ Last First Middle ADDRESS__________________________________________________________________________________ Street City State and Zip PHONE NO. (______)_______________ Social Security # __________________________________________ I Am Interested: Clerical______ Custodial_____ Maintenance_____ Food Service ____ Bus Driver _______ Para ______ Full Time ________ Part Time ________ Hours Available ____________________________ Date Available_____________________ How long do you plan to work? ________________________ Is Applicant Bonded?________ If Currently Employed: Employer:_______________________________________________________________ Position _________________________________________________________________ Duties __________________________________________________________________ Date Started _____________________Present Salary ___________________________ May we contact your present employer? ______________________________________ Immediate Supervisor’s Name ______________________________________________ Previous Employment: Start with most recent Company/Name & Address

Phone Number

Job Titles & Duties

Dates Employed

Education: Highest Grade Completed in High School _______________________ Date Completed _______________ College ________________________ Date Completed ________________Area of Instruction _____________________ List Personal References:

Name/Address/Phone #/Occupation

New employees will be on probation until removed according to prevailing policy. New employees must pass a physical examination. This application will be valid for 12 months.

COMPLETE THE SECTION PERTAINING TO THE POSITION APPLYING FOR CLERICAL (Clerical test may be required) Net Typing Speed ___________________________ Shorthand Speed __________________________ Bookkeeping Experience _______________________________________________________________ Indicate office machines you feel competent to operate: Calculator ________ Copier _________ Computer-PC or MAC-Programs ________________________________________________ Other special skills or experience _________________________________________________ CUSTODIAL AND MAINTENANCE Have you operated a heating and ventilating system? _______________________________________ Do you have a CDL license? ______________ Indicate trades in which you have had experience: ________ Carpenter

________ Mason

________ Farmer

________ Machinist

________ Painter

________ Engineer

________ Electrician

________ Plumber

________ Custodian

________ Truck Driver ________ Landscape/Gardener

__________________________________________ Other FOOD SERVICE Have you ever worked in a school lunch program? _____________ How many years? ____________ Have you ever attended the ISU courses for food service? _______ What course? _______________ BUS DRIVER Have you ever worked as a bus driver?_________________ For how many years? _______________ Have you attended or are you willing to attend the Bus Driver Training Course? ________________ Do you have a CDL license? _______ Have you worked with students before? __________________ If yes, in what capacity? ________________________________________________________________ Have you driven large vehicles before? __________ If yes, when and what type?________________ Have you driven large vehicles before? __________If yes, when and what type?________________________ PARA Have you ever worked as a para?_______Have you taken any para educator courses?_________ Have you worked in a day care or school setting before?_____________If so, where__________________

Date

Signature I certify that to the best of my knowledge the above statements are true and correct. All applicants are subject to a background check before hiring.