Grant Parish School Board – Employment Application for Substitutes Official application for substitute employment positions. Δ Step 1 of 4 25% GRANT PARISH SCHOOL BOARDP.O. Box 208, Colfax, LA 71417(318) 627-3274APPLICANT INFORMATIONDate of Application(Required) MM slash DD slash YYYY Name First Middle Initial Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneEmail(Required) Cell Phone(Required)Other PhoneDriver's License NumberState of IssuePOSITION(S) APPLIED FORPosition(s) Applied For(Required) Substitute Teacher Substitute Paraprofessional Substitute Janitor/Sweeper Substitute Cafeteria Worker Substitute Bus Driver Substitute Bus Attendant SCHOOL / DEPARTMENT LOCATIONS TO SUBSTITUTESchool / Department Locations to Substitute(Required) Georgetown High Grant Junior High Grant High Pollock Elementary South Grant Elementary Verda Elementary Montgomery High Transportation Department GENERAL QUESTIONNAIREAre you a citizen of the United States?(Required) Yes No If no, are you authorized to work in the United States?(Required) Yes No Have you ever worked for GPSB before?(Required) Yes No If yes, when and what position?(Required)Are you a retiree returning to work?(Required) Yes No If yes, what date did you retire?(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you ever been convicted of a felony?(Required) Yes No If yes, please explain:(Required) EDUCATIONPlease list your education history below.High SchoolHigh School(Required)AddressFromToDid you graduate?(Required) Yes No DiplomaCollegeCollegeAddressFromToDid you graduate? Yes No DegreeOther Education / TrainingOtherAddressFromToDid you graduate? Yes No Degree / CertificateREFERENCESPlease list three professional references.Reference 1Full Name(Required)Relationship(Required)CompanyPhone(Required)AddressReference 2Full NameRelationshipCompanyPhoneAddressReference 3Full NameRelationshipCompanyPhoneAddress PREVIOUS EMPLOYMENTPlease list your previous employment, beginning with your current or most recent employer.Employment 1Company(Required)PhoneAddressSupervisorJob Title(Required)ResponsibilitiesFrom(Required)ToReason for LeavingEmployment 2CompanyPhoneAddressSupervisorJob TitleResponsibilitiesFromToReason for LeavingEmployment 3CompanyPhoneAddressSupervisorJob TitleResponsibilitiesFromToReason for Leaving DISCLAIMER AND SIGNATUREI certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I authorize the verification of all information provided above.Digital Signature (Full Name)(Required)Date(Required) MM slash DD slash YYYY AUTHORIZATION AND RELEASEIMPORTANT: READ CAREFULLY. Louisiana Revised Statutes 17:3884 provides that a school board considering the employment application of a person who has been evaluated in another school system shall request such person’s evaluation results as part of the application process and shall inform the applicant that his/her evaluation results will be requested. The applicant shall be given the opportunity to review any information received by the prospective employer as a result of such request and to provide any response or information the applicant deems appropriate. Please be advised, therefore, that the Grant Parish School Board will request evaluation results on you from each of the school districts you have listed in your application. You will be given an opportunity to review the evaluation results received and to provide a response or information if you would like to do so. Any written response or information you might provide will be retained with your application. Louisiana Revised Statutes 17:15 also requires all applicants for employment to be fingerprinted in order to assist in background checks of those individuals. Should it be determined that any applicant or employee has been convicted of one or more of the criminal offenses set forth in Louisiana Revised Statutes 17:587.1(C), then that applicant or employee is generally precluded from further employment with the school system. Louisiana Revised Statutes 17:81.9 further requires a school board receiving an application to request that all current and prior school board employers of the applicant provide it with all information in their records relative to instances of sexual misconduct with students committed by the applicant, if any. This law further provides that the applicant must release all such employers from liability arising from the release of such information to the prospective employer.Authorization and Release Certification(Required) I certify that the information which I have provided in the attached application is true and complete. I understand that furnishing false information or omitting information on this application could disqualify me from consideration for employment or could lead to my discharge from employment. I hereby authorize the Grant Parish School Board to request, receive, and review my prior evaluations and information relative to sexual misconduct with students, if any, from all of my current or previous school system employers. I further release the Grant Parish School Board and all current and former employers, their agents and employees from any liability connected with such disclosures and do hereby specifically authorize such employer(s) to release to the Grant Parish School Board such information and documentation as may be requested in connection with my application for employment with it. Printed Name(Required)Date(Required) MM slash DD slash YYYY Digital Signature (Full Name)(Required)BACKGROUND HISTORY QUESTIONNAIREHave you ever been terminated by a school system, resigned prior to the expiration of your contract, or asked to resign?(Required) Yes No If yes, please explain, identifying the employer, basis for termination or resignation, and date.(Required)Have you ever been convicted, pled guilty, or pled no contest to a felony or other serious offense?(Required) Yes No If yes, please explain, identifying the charge, jurisdiction and court involved, date of conviction or plea, and factual basis of charge(s).(Required)Have you ever engaged in or been accused of engaging in sexual misconduct with a minor/student or the abuse or neglect of a minor?(Required) Yes No If yes, please explain, identifying the conduct or alleged conduct in question, including date(s), employer at the time, criminal charges, jurisdiction and court involved, date of conviction or plea, and factual basis of the charge(s) or allegations.(Required)Have you been the subject of any investigation of alleged sexual misconduct involving a minor or student, abuse of a minor or student, or neglect of a minor or student?(Required) Yes No If yes, please explain, identifying the conduct or alleged conduct in question, including date(s), employer at the time, results of the investigation, criminal charges, jurisdiction, court involved, date of conviction or plea, and factual basis of the charge(s) or allegations.(Required)FINAL ACKNOWLEDGMENT AND SIGNATUREFinal Acknowledgment Certification(Required) I have read, understand, and acknowledge the foregoing notice, conditions, and directions for completing this application. I certify that the information provided herein and in the attachments hereto is accurate, true, and complete to the best of my knowledge. I further certify that I have not been convicted, pled guilty, or pled no contest to a felony or other serious offense, and have not engaged in physical or sexual misconduct, neglect, or abuse with or toward a student. I hereby waive my confidentiality with regard to my work record or criminal record and consent to and authorize the release of information, including that which may have been sealed, from my current or former employers and/or law enforcement personnel upon inquiry in reference to this application. I release anyone responding to such inquiry from any liability for providing such information. Digital Signature (Full Name)(Required)Date(Required) MM slash DD slash YYYY
