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USD 509 Classified Application

Please complete the form below. Required fields marked with an asterisk *

Contact Information

(email will be entered at the bottom of this form)

Address

State
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Are you authorized to work in the US on an unrestricted basis?*
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Have you ever been convicted of a felony, or completed a Diversion Agreement for a felony?*
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Position

Educational Data

College/University

Other Education

Work Experience

Are you related to any person employed by USD 509? *
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I hereby certify that the above information to the best of my knowledge is true, accurate and complete. Any misrepresentation or willful omissions of facts shall be sufficient cause for disqualification of this application or termination of employment. Furthermore, it is understood that this application and records become the property of the district, which reserves the right to accept or reject the application. I further agree to observe all rules, regulations and policies of the district.

I hereby authorize the district to conduct a work history, personal reference and/or criminal record inquiry now or at any time following employment to determine my acceptability for employment. I understand that if I become employed by USD 509, as part of my employment processing, I will be required to furnish the following: Official Social Security Card, Drivers License or State Issued ID Card, and Birth Verification. A State Certification of Health Form will be required before employment is complete. I also understand that if offered a position I may be required to pass a drug screen as part of my pre-employment medical examination. Such testing will be at the district’s expense. I hereby certify that this application is correct and complete to the best of my knowledge.

I authorize the district to request, receive and verify all information given on this application and release the district from all damages that may result from your doing so.

I authorize the district to conduct a criminal background investigation using any and all methods necessary to successfully complete such investigation and I release the district from all liability for any damages that may result from your doing so.

I hereby authorize the district to conduct work history, personal reference and/or criminal record inquiries now or at any time following employment to determine my acceptability for employment.

Signature of Applicant*
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USD 509, South Haven Schools does not discriminate on the basis of race, religion, color, national origin, sex, age, or disability in admission or access to, or treatment or employment in its programs and activities. Any person having inquiries concerning the South Haven School District’s compliance with the regulations implementing Title VI, Title IX, Americans with Disability Act or Section 504 is directed to contact the Superintendent at 229 Kickapoo St, South Haven, KS 67140 or at (620) 892-5215. This district official has been designated by the South Haven School District to coordinate the district’s efforts to comply with the regulations implementing these laws.

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