abernathy independent school district...employment application for substitute teacher certification...

Abernathy Independent School District

EMPLOYMENT APPLICATION FOR SUBSTITUTE TEACHER An Equal Opportunity Employer*

Date of application _______________________ Social Security number _________________

Per

son

al D

ata Name

Last First Middle Maiden Name

Current address Street/Box City State ZIP Code

Home phone Cell phone Other phone

Other name that may appear on records (Used for reference checks)

Po

siti

on

Dat

a

Credentials included with application:

Résumé

All teaching and professional certificates or licenses

All transcripts showing degrees

Have you been employed by Abernathy ISD in the past? Yes No

If you answered yes, provide dates of employment

Ed

uca

tio

n/T

rain

ing

Check the highest level of education attained:

High school graduate GED Less than two years of college

Two or more years of college Bachelor’s degree

Master’s degree Other training or education __________________

___________________________________________

Name and location of schools attended

Course of study and major/minor

Diploma, degree, certificate, or license held

Year graduated (College only)

EMPLOYMENT APPLICATION FOR SUBSTITUTE TEACHER

Cer

tifi

cati

on

Certificate or License Currently Held: None Valid Texas Valid Other State Texas Emergency Texas One-Year: Expires _________________________ Texas Temporary Administrative: Expires __________________________

Areas of Specialization:

Administrator All-Level Art Vocational(specify) Superintendent All-Level Health & PE _________________ Principal All-Level Music Nurse Midmanagement Administrator Librarian Visiting Teacher Elementary Counselor Supervisor Elementary & Kindergarten Special Education (specify) Other (specify) Secondary (Jr./Sr. High) _______________________ _________________

Tea

chin

g E

xper

ien

ce

List teaching experience beginning with most recent years.

Name and location of school

Type of assignment Dates taught Reason for leaving

Oth

er w

ork

Exp

erie

nce

Please provide a list of all other jobs or administrative positions you have held in the past 10 years. Attach additional sheets if necessary. Attach résumé if available.

School district/firm name

Position/title Dates employed Reason for leaving


Ass

ign

me

nt

Pre

fere

nce

s

Please list the days you are available to substitute and your assignment preferences. Day(s) of week Every day or only the following:

Monday Tuesday Wednesday Thursday Friday

Assignment Any of the following:

Elementary Intermediate Secondary Special Education Preferred campuses ________________________________________________________ _________________________________________________________________________

Are you receiving Texas Teacher Retirement (TRS) benefits? Yes No

(The amount if time that an individual receiving TRS benefits may be employed without effecting is governed by TRS rules and laws.)

Gen

eral

In

form

atio

n

Have you ever been convicted of, plead guilty or no contest (nolo contendre) to, or received probation, suspension, or deferred adjudication for a felony or offense involving moral turpitude (including, but not limit to, theft, rape, murder, swindling, and indecency with a minor)? Yes No If yes, please state where, when, and the nature of the offense ______________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

(A felony conviction is not an automation bar to employment. The district will consider the nature, date, and relationship between the offense and the position for which you are applying.)

Ref

eren

ces

Please list references the district can contact regarding your work history. Include all managers and supervisors who evaluated or supervised your performance at your last two employers.

Full name of reference

School district/firm

name

Mailing address

Position/title

Area code, phone number


Ver

ific

atio

n

I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application or dismissal from subsequent employment.

I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all such parties from liability for any damage that may result from furnishing the same to you.

I understand that the district is required by Texas Education Code to review criminal history of applicants.

Signature Date

This application becomes the property of the district. The district reserves the right to accept or reject it.

Please return application & attachments to: Superintendent’s Office Abernathy I.S.D. 505 7th Street Abernathy, TX 79311

CRIMINAL HISTORY RECORD INFORMATION REQUEST

Confidential*

The Abernathy Independent School District is required by Texas Education Code Chapter 22, Subchapter C to review the criminal history of applicants, employees, independent contractors, student teachers, and certain volunteers. Please print. Name ________________________________________________________________________ Last First Middle Social Security Number _________________________ Date of birth _____________________ Driver’s License _______________________________________ State and number Mailing Address ________________________________________________________________ Street City State Zip Sex: Male Female Ethnicity: Black White/Other I understand that the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for employment but will solely for the purpose of obtaining criminal history record information. _________________________________________________ Signature _________________________________________________ Date ____________________________ * This form will be removed for the application and filed separately in the HR office.

HR Services Copyright 12/15/2007 Texas Association of School Boards. All rights reserved.

DPS COMPUTERIZED CRIMINAL HISTORY (CCH) VERIFICATION

(AGENCY COPY)

I, __________________________________________, have been notified that a computerized criminal APPLICANT OR EMPLOYEE NAME (Please print) History (CCH) verification check will be performed by assessing the Texas Department of Public Safety

Secure Website and will be based on name and DOB information I supply.

Because the name based information is not an exact search and only fingerprint record searches

represent true identification to criminal history, the organization conducting the criminal history check for

background screening is not allowed to discuss any criminal history record information obtained using the name and

DOB method. Therefore, the agency may that I have a fingerprint search performed to clear any misidentification

based on the result of the name and DOB search.

For the fingerprinting process I will required to submit a full and complete set of my fingerprints for

analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System). I

have been made aware that in order to complete this process I must make an appointment with L1 Enrollment

Services, and submit a full and complete set of my fingerprints, request a copy be sent to the agency listed below,

and pay a fee of $24.95 to the fingerprinting services company, L1 Enrollment Services.

Once this process is completed and the agency received the data from the DPS, the information on my

fingerprint criminal history record may be discussed with me.

(This copy must remain on file by your agency. Required for future DPS Audits)

___________________________________ Signature if applicant or Employee _________________________________________ Date __________________________________ Agency Name (Please print) _________________________________________ Agency Representative (Please print) _________________________________________ Signature of Agency Representative ________________________________________ Date Rev. 02/2011

Please: Check and initial each Applicable Space

CCH Report Printed: YES ________ NO________ ________initial Purpose of CCH: ___________________________ Hire______ Not Hired ______ ________ initial Date printed: ______________ ________ initial Destroyed Date: ____________ ________ initial

Retain in your files

August Pay Period February Pay Period6/24/12 - 7/28/12 12/30/12 - 1/26/13Pay Date – 8/20/12 Pay Date – 2/20/13

September Pay Period March Pay Period7/29/12 - 9/1/12 1/27/13 - 2/23/13Pay Date – 9/20/12 Pay Date – 3/20/13

October Pay Period April Pay Period9/2/12 - 9/29/12 2/24/13 - 3/30/13Pay Date – 10/19/12 Pay Date – 4/19/13

November Pay Period May Pay Period9/30/12 - 10/27/12 3/31/13 - 4/27/13Pay Date – 11/20/12 Pay Date – 5/20/13

December Pay Period June Pay Period10/28/12 - 11/24/12 4/28/13 - 5/25/13Pay Date – 12/20/12 Pay Date – 6/20/13

January Pay Period July Pay Period11/25/12 - 12/29/12 5/26/13 - 6/22/13Pay Date – 1/18/13 Pay Date – 7/19/13

ABERNATHY I.S.D.PAYROLL CALENDAR

2012-2013

2010-2011 PEIMS Data Standards Appendix F: Ethnicity and Race Reporting Guidance

Exhibit 1A Texas Education Agency

Texas Public School Student/Staff Ethnicity and Race Data Questionnaire

The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC).

School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting.

Please answer both parts of the following questions on the student's or staff member's ethnicity and race. United States Federal Register (71 FR 44866)

Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one) Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other

Spanish culture or origin, regardless of race. Not Hispanic/Latino

Part 2. Race: What is the person's race? (Choose one or more) American Indian or Alaska Native - A person having origins in any of the original peoples of North and South

America (including Central America), and who maintains a tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American - A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

________________________________ ___________________________________ Student/Staff Name (please print) (Parent/Guardian)/(Staff) Signature

_____________________________________ ________________________________________ Student/Staff Identification Number Date This space is reserved for Local school observer – upon completion and entering data in student software system, file this form in the student’s permanent folder.

Observer Signature: Campus and Date: Texas Education Agency – March 2010

Ethnicity – Choose only one: _______ Hispanic / Latino _______ Not Hispanic / Latino

Race - choose one or more: _____ American Indian or Alaska Native _____ Asian _____ Black or African American _____ Native Hawaiian or Other Pacific Islander _____ White


2010-2011 PEIMS Data Standards Appendix F: Ethnicity and Race Reporting Guidance

Exhibit 1B Agencia de Education de Texas

Cuestionario de Information de Datos Raciales y de Etnicidad de EstudianteslMiembros de Personal de las Escuelas PCiblicas de Texas

El Departamento de Educacion de Estados Unidos (USDE) requiere que todas las instituciones estatales y locales de education, recopilen datos sobre etnicidad y raza de los estudiantes y de miembros de personal. Esta information es utilizada para los reportes estatales y federales asi como para reportar a la Oficina de Derechos Civiles (OCR) y a Ia Comision de Igualdad en el Empleo (EEOC).

Al personal del distrito escolar y los padres o representante legal de estudiantes que deseen matricularse en Ia escuela, se le requiere proporcionar esta informaciOn. Si usted rehOsa proporcionarla, es importante que sepa que el USDE requiere que los distritos escolares usen Ia observation para identification como ultimo recurso para obtener estos datos utilizados para reportes federales.

Favor de contestar ambas partes de las siguientes preguntas sobre la etnicidad y raza del estudiante asi como del miembro de personal. Registro Federal de Estados Unidos (71 FR 44866).

Parte 1. Etnicidad: e:,Es Ia persona HispanalLatina? (Escoja solo una respuesta) Hispano/Latino — Una persona de origen cubano, mexicano, puertorriqueno, centro o sudamericano o de otra

cultura u origen espariol, sin importar Ia raza. No Hispano/Latino

Parte 2. Raza. LCual es la raza de Ia persona? (Escoja uno o ma's de uno) Indio Americano o Nativo de Alaska — Una persona con origenes o de personas originarias de Norte y

Sudamerica (incluyendo America Central), y que mantiene lazes a apego comunitario con una afiliacion de alguna tribu.

Asiatico — Una persona con origenes o de personas originarias del Lejano Este, Sureste de Asia o el subcontinente indio, incluyendo, por ejemplo a Cambodia, China, India, Japan, Corea, Malasia, Pakistan, las Islas Filipinas, Tailandia y Vietnam.

Negro o Africo-Americano — Una persona con origenes de cualquier grupo racial negro de Africa. Nativo de Hawai u otras Islas del pacifico — Una persona con origenes a de personas originarias de

Hawai, Guam, Samoa u otras Islas del Pacifico. Blanco — Una persona con origenes de personas originarias de Europa, el Medio Este o el Norte de

Africa.

Nombre del Estudiante/Miembro de Personal Firma (Padre/Representante legal) (por favor use letra de imprenta)

Numero de Identification del Estudiante/Miembro del personal

8 /(Miembro de personal

Fecha

Agencia de Education de Texas — Marzo 2009



This space is reserved for Local school observer – upon completion and entering data in student software system, file this form in the student’s permanent folder.

Observer Signature: Campus and Date:



This space is reserved for Local school observer – upon completion and entering data in student software system, file this form in the student’s permanent folder.

Observer Signature: Campus and Date:

ABERNATHY INDEPENDENT SCHOOL DISTRICT

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT (CREDITS)

SUBMITTING INSTRUCTIONS:

1. Please sign form in ink. 2. Bring this form & a void check for verification of your bank routing # and your account #. 3. Retain one copy for your records.

NAME __________________________________________SOC. SEC. NO. ____________________

CHECK ONE: ADD NEW CHANGE EXISTING CANCEL ACCOUNT ACCOUNT ACCOUNT

CHECK ONE: CHECKING SAVINGS Amount $ _____________________ If no specific amount, put ALL If change, put new amount

BANK / DEPOSITORY NAME _______________________________________________________

BANK ACH ROUTING # _______________________________ ACCOUNT# _________________ Verified by payroll (First nine digits at bottom of check) Verified by payroll

The Abernathy ISD is not responsible for overdraft charges that might result from an inactivated account. I hereby authorize Abernathy ISD hereinafter to initiate credit entries, and if errors occur, authorizing correcting entries to my ACCOUNT and depository named above to credit the same or change amounts as stated above.

SIGNATURE______________________________________________ DATE__________________________

OFFICE USE ONLY

PRENOTE DATE _____________________________ ACTIVE DATE _________________________

BANK CODE# _______________________________

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