McCabe Union Elementary School District 701 W. McCabe Rd., El Centro, CA 92243 (760) 335-5200 Fax (760) 352-4398

http://www.mcusd.net

Certificated Employment Application

Positions You Are Applying And For Which You Are Qualified On Credential

Subject(s), Grade level(s), or Non-teaching position(s) according to perference:

First Choice Alternate Choice

Other subjects you are qualified to teach, activities to direct or positions to fill.

Are you willing to work? substitute short time part time full time

Date available to start working Specify days and hours available to work if not full time

Date of Application

First Name Middle Last

Phone # Last 4 digits of SS #

Current Address City State ZIP

Permanent Address

Other

Do you have a legal right to reside and seek employment in the U.S.? Yes

Are you related by blood, marriage, or law to any employee or member of the Governing Board? Yes No If yes ,who?

Were you previously employed by MUESD? Yes No If yes, when and in what capacity?

Language(s) other than English that you speak and write? NoneLanguage Speak Read Write Translate

If yes, please list language(s) and level of fluency.

Do you have a physical condition that may limit your ability to perform employment with us? Yes No

If yes, explain:

Valid California Driver's License No.

Cell #

No

E-mail Address

Personal Information

The McCabe Union Elementary School District is an Affirmative Equal Opportunity Employer

Please send to the attention of:Human Resources McCabe Union Elementary School District 701 W. McCabe Rd. El Centro, CA 92243

Please include:

Signed Employment Application Cover Letter

Three (3) letters of recommendation

Copies of current credential(s)Copies of college / university transcripts

Copies of CBEST, NTE, PRAXIS, MST

College or University Education Name and Location of each Institution Attended

Attended From To

Graduated Date Degree Major Minor

(1 Quarter unit = 2/3 semester unit)Number of semester units of graduate work beyond BA/BS Beyond MA/MS

Please attach a copy of transcripts, diploma, credentials, certificates, HQT status, and proof of exams passed (CBEST / CSET).

Highest degree received

MCUSD Certificated Application Page 2 of 3

Credential applying for Application Date

Language Certification None LDS /CLAD BCC / BCLAD SDAIE Other

Examinations completely passed CBEST

Date

CSET

Date

Other

Type of Credential Credential Number Expiration Date Preliminary Clear

Valid California Credentials Currently Held

Note: Teachers new to the profession who earn their credential in California usually have Language Certification embedded in their credential.

Public School Experience

Type From To Grades or Subjects School Location and City Reason for Leaving

(List last position first. If more than five years, list positions from last five years. If none, report student teaching experience. Indicate type: Regular, Substitute or Student Teaching.)

Recommendations / ReferencesName of a principal or master teacher whom you will authorize us to phone for an immediate recommendation

Name

Address Phone

Position

List names, addresses, telephone numbers, and titles of supervisors in most recent positions who are familiar with your performances and character excluding relatives and, if none, include persons familiar with your character and their relationship to you.

Name Address Phone Position / Relationship

Employment Conditions

Filing Application: Application must be filed in the District Office on or before the final filling date.

Verification: All statements made on this application may be verified, including checks of your fingerprints, police records and former employers.

Medical Certification: After an offer of employment has been made, it may be conditioned upon the submission of medical information including, but not limited to, information regarding the results of tuberculosis testing.

Citizenship and Age. Pursuant to the Immigration Reform and Control act of 1986, I understand that any offer of employment which may be made to me will be conditional on my ability to provide proof of identification and legal right to work in the United States. I also understand that I may be required to provide proof of my birth date.

Offer of Employment. If you are provided with an offer of employment, such employment is wholly conditional upon formal action of the Governing Board and is not binding on the District until such action is taken and a fingerprint clearance is received.

Contact with School Board Members. An applicant may not contact individual board members in an effort to influence the hiring process. If an applicant does so, he/she shall be disqualified for the position.

I, authorize the McCabe Union Elementary School District to make any investigation of my personal or employment history and authorize any former employer, person, firms, corporation or government agency to give the McCabe Union Elementary School District any information they may have regarding me. In consideration of the McCabe Union Elementary School District of this application, I release the McCabe Union Elementary School District from liability as a result of furnishing and receiving this information

Employment Background Disclaimer

Signature of ApplicantDate

Certification of Application Please Read Carefully Before You SignI certify that I have carefully reviewed this application for employment, that all information provided by me on this application, the contents of

documents provided by me, and all statements which I have made or will make in any interview connected with this application, are true and complete. I understand that giving false, misleading, incomplete information may be reason for non-selection, withdrawal of an offer of employment, non-reemployment, termination of employment, or cause for discipline to include suspension or dismissal. I authorize agents of the McCabe Union Elementary School District to investigate and verify all statements made on this application to include contacting my previous employers and references provided by me. I authorize the individuals listed as references herein and the agents or employees of my former employers to answer any inquiry relevant to my application, and hereby release the foregoing individuals from any and all liability whatsoever for responding to such inquiries.

I understand that this application is not a contract, and is not an offer of employment. If I am offered employment, I understand that such offer is subject to the Employment Conditions above.

Signature of ApplicantDate

MCUSD Certificated Application Page 3 of 3

IMPORTANT: Read all the questions below before answering any of them and ask for clarification if you do not understand any question. For the purpose of these questions, a criminal “conviction” means a plea of guilty or nolo contendere, verdict or finding of guilt even if a sentence is not imposed. The receipt of a certificate of rehabilitation and pardon, or a dismissal of the charges pursuant to Section 1203.4 of the Penal Code does not relieve you of the obligation to disclose any conviction in response to the following questions. However, the existence of a criminal record does not constitute an automatic bar to employment except where required by law.

1. Have you ever been convicted of any sex offense? Yes No

3. Have you ever been convicted of any other criminal offense? Yes No

4 Has your credential ever been revoked or suspended? Yes

Yes

No

No

Character History

If the answer to this question is “yes” answer it “no” only if (1) the record of the conviction has been judicially expunged, sealed and eradicated, such as in the case of some juvenile offenses, or (2) the conviction has been reversed and the charges dismissed, or you have been acquitted after a new trial

Have you ever been dismissed from employment or had your employment terminated or asked to resign? 5.

2. Have you ever been convicted of any felony involving a controlled substance? Yes No

Have you ever been dismissed from employment or had your employment terminated, asked to resign, or resigned with disciplinary action or termination pending from any certificated position?

6. Yes No

Fully explain any “Yes” answers to the above questions on additional attached pages.

For Questions # 1 to # 3: