Date of Application _________________________________
I hereby make application for employment as _________________________________________________
and state that the information furnished on this form is true to the best of my knowledge and belief.
___________________________________________
Signature
______________________________________________________________________________________
Last Name First
Name Middle
Name
____________________________________________________________________________________________________________
Home Address Mailing
Address
____________________________________________________________________________________________________________
City State Telephone
Number
Are you a citizen of the
Have you resided outside the
state of
If so, when: _________________
In case of accident, notify:
______________________________________________________________________________________
Name Address Telephone
Number Relation
Education (Circle the highest year completed)
Public Schools: 1 2 3 4 5 6 7 8 9 10 11 12
Name of School Major
College: ______________________________________________________________________________
Name of College Major
Previous Employment:
______________________________________________________________________________________
Name of Employer Address Position
____________________________________________________________________________________________________________
Date (From) Date (To) Rate per Hour, Week, or Month Name and Title of Immediate
Supervisor
Briefly, describe your duties in the above position:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Reason for leaving the above position:
______________________________________________________________________________________
______________________________________________________________________________________
If you are employed now, what is your:
Position ____________________________________ Since __________________________________
Immediate Supervisor _________________________ Department _____________________________
May we contact your employer? ______________________
Foreign language spoken? ___________________________
Have you ever been convicted of a crime? _______________________
Give record of such and disposition _________________________________________________________
______________________________________________________________________________________
Give any other pertinent information ________________________________________________________
Give names and addresses of three references (other than relatives)
______________________________________________________________________________________
RECORDS INVESTIGATION
The Frederick Board of
Education believes that it has a responsibility to employ only those persons
who are qualified in every respect. The
board further believes that it should avail itself of means and methods
provided by the legislature to assist in the selection of employees. Therefore, it is the policy of this board of
education that a felony records check may be conducted of a prospective
employee at the superintendent's discretion.
A written consent will be required from the prospective employee
consenting to a felony records check to be conducted as authorized by
Any person applying for employment as a substitute teacher shall only be required to have one such felony records search for the school year. Upon request of the substitute teacher, that felony records search results may be sent to any other school district in which the substitute teacher is applying to teach. (HB 1321)
The superintendent will determine whether to request a felony records check of the prospective employee. If the superintendent determines to conduct the felony records check, the superintendent may decide to check the employee's name only or name and fingerprints. Further, the superintendent is authorized to request a state only check, or a state and national search. Such determinations will be made at the discretion of the superintendent.
If the superintendent requests that a national records search be conducted, the prospective employee will be required to furnish a fingerprint card to the Oklahoma State Bureau of Investigation (OSBI) and must pay to the OSBI the cost of the records search up to $50.00.
If the applicant for employment meets all other criteria for employment in this school district, the applicant may be employed on a temporary basis for up to sixty (60) days pending receipt of the felony records search results. If the applicant is offered permanent employment following the review of the records search, the OSBI search fee, if any, will be reimbursed in full.
REFERENCE: 70 O.S. §5-142
NOTE: A criminal record check of prospective teachers must be requested by the superintendent using a form supplied by the Department of Education. Since that form requires the employee's signature, it is suggested that the form be obtained and used in accordance with this policy.
NOTE: School
districts with more than 30,000 students will request background felony records
checks directly from the
FELONY RECORDS SEARCH
PROCEDURES
Pursuant to 70 O.S. §5-142, the Frederick School District will obtain the results of a state and/or national felony record search of the name and fingerprints of every prospective school district employee. During the first interview with each employment applicant, the applicant will be advised that:
1. The school district requires a state and/or national felony record search of every prospective employee’s name and/or fingerprints as a condition of employment; to qualify as a substitute, each substitute
2. Will enable the school district to request the search and obtain the results, the applicant must complete and sign an Authorization and Release form provided by the school district;
3. The school district will request a felony record search only if the superintendent of schools recommends employment of the applicant;
4. If the superintendent of schools recommends employment of the applicant, the applicant must pay the search fee, which will not exceed $50;
5. The school district will reimburse the applicant for the search fee unless the search discloses a prior felony offense conviction;
6. If the superintendent of schools recommends employment of the applicant, the applicant must permit the Oklahoma State Bureau of Investigation to fingerprint the applicant; and
7. The applicant, if placed on duty prior to receipt of the felony search results, will be classified as a temporary employee until the school district is notified that the search is clear of any felony record.
If the felony records search reveals a prior felony offense conviction or if the applicant provides a false response to one or more of the questions on the Authorization and Release, the applicant will be denied employment and, if placed on duty prior the receipt of the search results, will be deemed to have resigned from employment with the school district, effective upon acceptance by the board of education. The board of education may accept any employee’s resignation at any time within thirty (30) days after the date the school district is notified of either the unsatisfactory search results or learns of the applicant’s false response, whichever is later. Under these circumstances, the employee waives any due process procedures which might otherwise be available under federal and state law and school district policies and procedures.
The school district will also request a state and/or national felony record search of the name and fingerprints of any current school district employee if the board of education recommends a search of that employee’s felony record.
AUTHORIZATION AND RELEASE
This authorization and release is
executed under penalty of perjury on the ________ day of __________, ______, by
_______________________________________________________, applicant for
employment (“Applicant”)
with the Frederick School District No. 158,
Applicant understands that the
School District’s receipt of a clear state or national felony record search of
his/her name and fingerprints is a condition of employment with the
Applicant acknowledges that Applicant has be furnished and understands all of the requirements of the School District’s felony record search policy and agrees to be bound by all of its terms and conditions.
Applicant also agrees to truthfully answer the following questions:
Have you ever:
Yes No
1. Entered a plea of guilty or nolo contendere to a state or federal felony charge? ____ ____
2. Been convicted of a state or federal felony offense: ____ ____
3. Been charged with a state or federal felony offense which was reduced to a
misdemeanor offense to which you entered a plea of guilty or nolo contendere? ____ ____
4. Entered a plea of guilty or nolo contendere to, or been convicted of, a state or federal
misdemeanor charge involving illegal chemical substances or illegal sexual activity? ____ ____
Applicant
understands that if Applicant is hired by the
_____________________________________
Applicant’s Signature
RECORDS INVESTIGATION
CONSENT
The name and fingerprints of an applicant for employment with this school district may be submitted to the Oklahoma State Bureau of Investigation for a state and/or national felony records search. Such a search will require that you be fingerprinted by the OSBI, or designee, and that you pay the cost of the search up to $50.00. If you are subsequently employed or are employed for a temporary period pending the receipt of the search results, then the district will reimburse you for the cost of the search. The school district may conduct a national felony records search of any current school employee if the board of education recommends the search.
I state that I have read the above requirements and do consent to being fingerprinted. I will pay the fee for an OSBI felony records search if so requested by the school district.
Signed this ________ day of ___________________________ , _____________.
_________________________________________
Applicant