SUPPORT STAFF APPLICATION BATH LOCAL SCHOOLS 2650 BIBLE ROAD LIMA, OH 45801

Date of Application__________________

Name__________________________________________________________________________________________ Last	First	Middle

Address_________________________________________________________________________________________ Street & Number	City	State	Zip

Telephone Number: _________________________	Alternate Phone Number: ___________________________

Position(s) for which you are applying: (check)

DEPARTMENT
	APPLYING FOR THE POSITION (x)
	WOULD SUBSTITUTE (y/n)
	
Bus Driver

Bus Aide

Bus Mechanic

Custodial

Food Service

Library Assistant**

Maintenance

Monitor: Café and Playground*

Monitor: Study Hall*

School Nurse – RN Required

Secretary

Teacher’s Aide**

Coach for :

*Monitor permits can be obtained from Ohio Department of Education. **Teacher’s Aide and Library Assistants must hold an ESEA qualified Aide Permit

All positions, staff and substitute, require FBI and BCI background check

Education and Technical Training

School Attended

________________________

________________________

________________________

Name & Location

_________________________

_________________________

_________________________

Degree

__________________

__________________

__________________

Graduation Date

_________

__________

__________

Previous Work Experience

Start with present or most recent employer

Employer________________________________________

Address_________________________________________

Name of Supervisor_______________________________

Telephone____________________________

Employed From-To____________________ (Month-Year)
Reason for Leaving____________________

State Job Title & Describe Your Work________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Employer_______________________________________

Address________________________________________

Name of Supervisor______________________________

Telephone____________________________

Employed From-To____________________ (Month-Year)
Reason for Leaving____________________

State Job Title & Describe Your Work________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Employer_____________________________________

Address______________________________________

Name of Supervisor____________________________

Telephone____________________________

Employed From-To____________________ (Month-Year)
Reason for Leaving____________________

State Job Title & Describe Your Work________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Complete sections applicable to your application Attach copy of licenses or permits pertaining to position

Bus Driver

Number of years’ experience driving: Bus ____ Semi-Truck ____	CDL Certified? ______

License No.________________________	Endorsement________________	Class______________

Driving Record – Have you ever had your license revoked?	Yes____	No____

Conviction of a felony?

Conviction of a DUI?

Yes____	No____

Yes____	No____

Have you completed Bus Driver Training Course?	Yes____	No____	Date___________

Custodial

Number of years custodial experience ________

School__________	Hospital_________	Nursing Home__________	Other__________

Knowledge of institutional cleaning products – list ______________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Food Service

Experience in cooking/serving large groups?	Yes____	No____

Number of years’ experience in food service ______________

Hospital__________	Nursing Home__________	School__________	Other ______________________

Have you any experience in working with the following?

Running register/handling cash ____	Steam Table____	Ovens____

Mixer-Grinder____	Commercial Dish Machine ____

Maintenance/Grounds List experience
HVAC___________________________________________________________________________________

Plumbing_________________________________________________________________________________

Electrical_________________________________________________________________________________

Welding__________________________________________________________________________________

Groundskeeping Equipment__________________________________________________________________

Secretarial Office Professional
Office equipment – Are you proficient in the following?

Computer____	Windows XP____	Windows 2000____	Word____	Excel____

Copy Machines_____	Typing wpm______	Power Point_______	Google_______

Aide/Monitor

Aide Certificate #_______________ Expiration Date _______ ESEA Qualified? _________

Physical ability to transfer students_______

Previous experience working with children with disabilities_______

Coach
PAS Certificate #___________________	Expiration Date _______

References
Please list at least three (3) people (non-relatives), along with addresses and phone numbers, who have knowledge of your character and your work habits.

Name________________________

Name________________________

Name________________________

Position__________________ Address_______________________

Position__________________ Address_______________________

Position__________________ Address_______________________

Phone #___________

Phone #___________

Phone #___________

Personal/Related Information

Have you attended school or work under another name? Y / N	Name___________________________________

Have you ever served in the United States military?	Y / N	Branch_________________________ Yrs: _______

If currently employed, why do you want to leave your present position?______________________________________

_______________________________________________________________________________________________

Statement

Please write a brief paragraph explaining (1) why you are interested in the position and (2) the major reasons why you feel you qualify for the position.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Certificate of Applicant

I hereby authorize the Bath Local Schools to obtain from my former employers all data needed to support this application. I hereby authorize Bath Local Schools to obtain from the references listed above any information needed to support this application.

I acknowledge being informed that as a precondition to employment in the position for which I am applying, I must in accordance with Ohio law provide both a set of fingerprints and satisfactorily pass a criminal records check if I come under final consideration for employment.

I represent that all information furnished in connection with this application is true and accurate to the best of my knowledge. I fully understand that any person who knowingly makes a false statement is guilty of falsification under O.R.C. section 2921.13, which is a misdemeanor of the first degree. I further recognize that, should the employer discover that I have falsified any such information, I will not be hired, or if already hired, will be subject to termination from employment on those grounds.

__________________________________________ Signature of Applicant

_______________________________ Date

I agree that any claim or lawsuit relating to my service with the Bath Local School District must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I hereby forever waive any statute of limitations to the contrary.

If you are hired, this application becomes part of your official employment record, and you will be bound by its terms.

Your signature below is your acknowledgement that you have read and understood this application, and that your responses have been truthful and complete.

_________________________________________ Signature of Applicant

_________________________________ Date

Bath Local Schools
An Equal Opportunity Employer