CENTERVILLE COMMUNITY SCHOOL DISTRICT
P.O. Box 370 Centerville, Iowa 52544

APPLICATION FOR EMPLOYMENT -- CAFETERIA

Position Desired
 	  Food Preparation
 	  Server

PERSONAL INFORMATION

Name				 Last	First	Middle

Address					 Street/P.O. Box	City	State	Zip

Telephone:	Home 		Office  	

Social Security #  	

Have you completed the 10 or 12 hours Sanitary Course?  	

IV. EDUCATION	| Name & Location	| Years	|	|		
High School	|
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College	|
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Trade,	|	|	|	|		
Business,	|	|	|	|		
Correspondence	|	|	|	|		
School	|	|	|	|		

MILITARY RECORD	

Branch 		Dates  	

Check if military service includes any of the following times:

 	6-25-50 through 1-31-55
 	8-5-64 through 5-7-75
 	8-2-90 to present

EMPLOYMENT RECORD (List all employment and experience history starting with the most recent.

|Dates	| Name, Address, & Phone of Employer	| Salary	|	Immediate Supervisor	|		
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|	Duties		Reason for Leaving	|		
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|Dates	| Name, Address, & Phone of Employer	| Salary	|	Immediate Supervisor	|		
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|Dates	| Name, Address, & Phone of Employer	| Salary	|	Immediate Supervisor	|		
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Please attach a complete record or resume of your work experience.

Please describe in detail any experience you have had that would prepare you for this job:  	

Are you on a sex offender registry?	 	YES	 	NO
Are you on the Department of Human Services' child abuse registry?	 	YES	 	NO
Are you on the Department of Human Services’ dependent adult abuse registry? 	YES 	NO
Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)? 	YES 	NO If yes, please provide date, incident, city/state of charge:

Responding "yes" to any of the previous questions is not an automatic bar to employment. The date of the offense, and the relationship between the offense and the position for which you are applying will be considered.

Is there any name, other than the name stated above, which you have previously used to identify yourself:

I HEREBY CERTIFY, THAT THE INFORMATION ON THIS APPLICATION IS COMPLETE, ACCURATE AND TRUE. I AM AWARE THAT ANY MISREPRESENTATION OR FALSIFICATION ON THIS APPLICATION WILL RESULT IN DISQUALIFYING THE APPLICATION AND POSSIBLE TERMINATION. I FURTHER UNDERSTAND ANY JOB OFFER MADE BY THE ADMINISTRATION IS PENDING FINAL APPROVAL BY THE SCHOOL BOARD.

Have you ever been convicted of a felony?  	

** This application will remain on file for 90 days.

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Applicant's Signature	Date

AA/Equal Opportunity Employment Equity Coordinator – Susan McDanel

DO NOT WRITE BELOW THIS LINE
INTERVIEWED BY 		DATE  	

Remarks  	

Agreement

I hereby certify that the above information, to the best of my knowledge, is true, accurate and complete. Any misrepresentation or willful omissions of act shall be sufficient cause for disqualification of this application or termination of employment.

I authorize verification of any of this information. I grant my permission for those reviewing my application to contact all references and employers (past and present) whether or not listed on the application form. I authorize all current and former employers and references to release  any  information concerning my background. I authorize and hold harmless the Centerville Community School District and its employees to make all necessary and appropriate investigations to verify the information contained in the application form. I release any defamation claim I might have because a former employer or reference who disclosed facts and opinions regarding my prior work performance, character and fitness to work with and around children.

I understand that this application is not a contract of employment. I understand any job offer made by the administration is pending final approval by the school board of directors. I also understand that if hired, regardless of any oral representations to the contrary, the employment relationship is terminable- at-will as allowed by state and federal laws.

I authorize a criminal background investigation.

Signature

Social Security #

Applications for this and similar positions will be accepted until 	.