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NOTE: To ensure the document saves your information correctly, first download form and open in Adobe Reader before filling out. Thank you. STATE OF MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION P.O. Box 480, 205 Jefferson Street, Jefferson City, MO 65102-0480 APPLICATION FOR EMPLOYMENT OUR VISION: Missouri public schools: the best choice...the best results!To applicants with disabilities, if you have difficulty with any phase of the employment process, please call 573-751-9619. Reasonable attempts will be made to accommodate special needs. TTY/TDD users, please call the Relay Missouri number at 1-800-735-2966 or the 711 Relay Operator. IDENTIFICATION LAST NAME FIRST NAME MIDDLE HOME PHONE NO. WORK PHONE NO. EMAIL ADDRESS PRESENT MAILING ADDRESS (STREET AND NUMBER, RFD OR P.O. BOX) CITY STATE ZIP ARE YOU LAWFULLY AUTHORIZED TO WORK IN THE U.S.? YES NO The Department is unable to sponsor applicants in their application for work visas through INS. If you have questions, please contact Human Resources. POSITION (PLEASE COMPLETE ONE APPLICATION FOR EACH POSITION FOR WHICH YOU ARE APPLYING) TITLE OF POSITION FOR WHICH YOU ARE APPLYING VACANCY NO. CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION AS LISTED ON THE VACANCY NOTICE? YES NO TYPE OF EMPLOYMENT DESIRED: FULL-TIME PART-TIME TEMPORARY WHEN COULD YOU START WORK? MINIMUM SALARY EXPECTATION HOW DID YOU LEARN ABOUT THIS VACANCY? EDUCATION HIGH SCHOOL GRADUATE OR GENERAL EDUCATION DEVELOPMENT TEST SCHOOL NAME AND LOCATION YES NO CHECK HIGHEST GRADE COMPLETED 1 2 3 4 5 6 7 8 9 10 11 12 POST HIGH SCHOOL EDUCATION/TRAINING (COPIES OF THE OFFICIAL TRANSCRIPTS ARE REQUIRED) NAME AND LOCATION OF SCHOOL CREDITS EARNED DEGREE MAJOR OR EARNED SUBJECTS TAKEN DO YOU HAVE RELATIVES WORKING FOR THIS DEPARTMENT? YES NO IF YES, PLEASE NAME. QTR HOURS SEM HOURS OTHER MO 500-1990 (Rev. 03-17) • AN EQUAL OPPORTUNITY EMPLOYER •
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DESE Employment Applicationmsb.dese.mo.gov/documents/hr-employment-application2.pdf · 2017. 4. 3. · ew, DESE reserves the right to ask questions about my criminal history and that

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  • NOTE: To ensure the document saves your information correctly, first download form and open in Adobe Reader before filling out. Thank you.

    STATE OF MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION P.O. Box 480, 205 Jefferson Street, Jefferson City, MO 65102-0480 APPLICATION FOR EMPLOYMENT

    OUR VISION: “Missouri public schools: the best choice...the best results!”

    To applicants with disabilities, if you have difficulty with any phase of the employment process, please call 573-751-9619. Reasonable attempts will be made to accommodate special needs. TTY/TDD users, please call the Relay Missouri number at 1-800-735-2966 or the 711 Relay Operator.

    IDENTIFICATION

    LAST NAME FIRST NAME MIDDLE

    HOME PHONE NO. WORK PHONE NO. EMAIL ADDRESS

    PRESENT MAILING ADDRESS (STREET AND NUMBER, RFD OR P.O. BOX) CITY STATE ZIP

    ARE YOU LAWFULLY AUTHORIZED TO WORK IN THE U.S.? ❑ YES ❑ NO The Department is unable to sponsor applicants in their application for work visas through INS. If you have questions, please contact Human Resources.

    POSITION (PLEASE COMPLETE ONE APPLICATION FOR EACH POSITION FOR WHICH YOU ARE APPLYING)

    TITLE OF POSITION FOR WHICH YOU ARE APPLYING VACANCY NO. CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION AS LISTED ON THE VACANCY NOTICE?

    ❑ YES ❑ NOTYPE OF EMPLOYMENT DESIRED:

    ❑ FULL-TIME ❑ PART-TIME ❑ TEMPORARY

    WHEN COULD YOU START WORK?

    MINIMUM SALARY EXPECTATION

    HOW DID YOU LEARN ABOUT THIS VACANCY?

    EDUCATION

    HIGH SCHOOL GRADUATE OR GENERAL EDUCATION DEVELOPMENT TEST SCHOOL NAME AND LOCATION

    ❑ YES ❑ NOCHECK HIGHEST GRADE COMPLETED

    ❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑ 8 ❑ 9 ❑ 10 ❑ 11 ❑ 12

    POST HIGH SCHOOL EDUCATION/TRAINING (COPIES OF THE OFFICIAL TRANSCRIPTS ARE REQUIRED)

    NAME AND LOCATION OF SCHOOL CREDITS EARNED DEGREE MAJOR OR EARNED SUBJECTS TAKEN

    DO YOU HAVE RELATIVES WORKING FOR THIS DEPARTMENT? ❑ YES ❑ NO IF YES, PLEASE NAME.

    QTR HOURS

    SEMHOURS OTHER

    MO 500-1990 (Rev. 03-17) • AN EQUAL OPPORTUNITY EMPLOYER •

    Text Boxemail: [email protected]

  • SKILLS AND EQUIPMENT CLERICAL SKILLS

    OFFICE MACHINES AND

    EQUIPMENT YOU CAN

    OPERATE

    COMPUTERS YOU CAN

    OPERATE

    SOFTWARE PACKAGES

    YOU HAVE USED

    TYPING SPEED (WPM) __________________ SHORTHAND? ❑ YES ❑ NO DATE OF LAST TEST ____________________ IF YES, SPEED (WPM) _______________

    ❑ PC ❑ MACINTOSH ❑ OTHER ___________________________________________

    HAVE YOU USED THE SAM SYSTEM? ❑ HR ❑ ACCOUNTING ❑ BUDGET ❑ TIMEKEEPING

    CURRENTLY VALID LICENSES/CERTIFICATES (RELATIVE TO MINIMUM QUALIFICATIONS LISTED ON THE VACANCY NOTICE)

    DO YOU HAVE A VALID DRIVER’S LICENSE? ❑ YES ❑ NO ❑ NOT APPLICABLE TO VACANCY

    DO YOU HAVE A VALID MISSOURI CHAUFFER’S LICENSE? ❑ YES ❑ NO ❑ NOT APPLICABLE TO VACANCY

    DO YOU HAVE A VALID MISSOURI COMMERCIAL DRIVER’S LICENSE? ❑ YES ❑ NO ❑ NOT APPLICABLE TO VACANCY

    DO YOU HAVE A VALID MISSOURI SCHOOL BUS OPERATOR’S PERMIT? ❑ YES ❑ NO ❑ NOT APPLICABLE TO VACANCY

    DO YOU HOLD A VALID MISSOURI TEACHING CERTIFICATE? ❑ YES ❑ NO ❑ NOT APPLICABLE TO VACANCYIF YES, PLEASE LIST.

    OTHER LICENSE OR CERTIFICATE

    OTHER LICENSE OR CERTIFICATE

    LICENSE OR CERTIFICATE NO.

    LICENSE OR CERTIFICATE NO.

    COMMENTS

    MO 500-1990 (Rev. 03-17) • AN EQUAL OPPORTUNITY EMPLOYER •

  • EMPLOYMENT HISTORY

    Please complete this section starting with your present or most recent employer. Use additional sheets of paper if necessary.

    EMPLOYER’S NAME LIST DUTIES PERFORMED

    ADDRESS

    YOUR JOB TITLE

    FROM (MO/YR) TO (MO/YR)

    HOURS PER WEEK LAST MO. SALARY

    SUPERVISOR’S NAME AND TITLE

    PHONE NO.

    MAY WE CONTACT YOUR SUPERVISOR? ❑ YES ❑ NO IF NO, WHY?

    REASON FOR LEAVING

    EMPLOYER’S NAME LIST DUTIES PERFORMED

    ADDRESS

    YOUR JOB TITLE

    FROM (MO/YR) TO (MO/YR)

    HOURS PER WEEK LAST MO. SALARY

    SUPERVISOR’S NAME AND TITLE

    PHONE NO.

    MAY WE CONTACT YOUR SUPERVISOR? ❑ YES ❑ NO IF NO, WHY?

    REASON FOR LEAVING

    EMPLOYER’S NAME LIST DUTIES PERFORMED

    ADDRESS

    YOUR JOB TITLE

    FROM (MO/YR) TO (MO/YR)

    HOURS PER WEEK LAST MO. SALARY

    SUPERVISOR’S NAME AND TITLE

    PHONE NO.

    MAY WE CONTACT YOUR SUPERVISOR? ❑ YES ❑ NO IF NO, WHY?

    REASON FOR LEAVING

    MO 500-1990 (Rev. 03-17) • AN EQUAL OPPORTUNITY EMPLOYER •

  • I certify that the information provided herein is true and complete to the best of my knowledge. I understand misrepresentation or omission of information on this application and/or inserts, including relatives working for the

    EMPLOYER’S NAME LIST DUTIES PERFORMED

    ADDRESS

    YOUR JOB TITLE

    FROM (MO/YR) TO (MO/YR)

    HOURS PER WEEK LAST MO. SALARY

    SUPERVISOR’S NAME AND TITLE

    PHONE NO.

    MAY WE CONTACT YOUR SUPERVISOR? ❑ YES ❑ NO IF NO, WHY?

    REASON FOR LEAVING

    EMPLOYER’S NAME LIST DUTIES PERFORMED

    ADDRESS

    YOUR JOB TITLE

    FROM (MO/YR) TO (MO/YR)

    HOURS PER WEEK LAST MO. SALARY

    SUPERVISOR’S NAME AND TITLE

    PHONE NO.

    MAY WE CONTACT YOUR SUPERVISOR? ❑ YES ❑ NO IF NO, WHY?

    REASON FOR LEAVING

    BUSINESS REFERENCES

    In the space below, list the name, address, and phone number of three references who can verify your ability to perform the essential functions of the position as listed on the vacancy notice.

    NAME ADDRESS DAYTIME PHONE NO.

    EVENING PHONE NO.

    I accept this condition. Type Name here Date NOTICE OF NONDISCRIMINATION: The Department of Elementary and Secondary Education does not discriminate on the basis of race, color, religion, gender, national origin, age, or disability in its programs and activities. Inquiries

    related to Department programs and to the location of services, activities, and facilities that are accessible by persons with disabilities may be directed to the Jefferson State Office Building, Office of the General Counsel, Coordinator – Civil

    Rights Compliance (Title VI/Title IX/504/ADA/Age Act), 6th Floor, 205 Jefferson Street, P.O. Box 480, Jefferson City, MO 65102-0480; telephone number 573-526-4757 or TTY 800-735-2966; email [email protected].

    MO 500-1990 (Rev. 03-17)

    lstrangeSticky NoteUnmarked set by lstrange

    lstrangeSticky NoteMigrationConfirmed set by lstrange

    lstrangeSticky NoteAccepted set by lstrange

    lstrangeSticky NoteNone set by lstrange

    lstrangeText BoxI certify the above statements are correct and complete and, if employed, understand that any false or omitted information in this application or its supporting documents will be sufficient grounds for immediate termination. My signature authorizes the Missouri Department of Elementary and Secondary Education (DESE) to review my previous employment, driving and criminal records and order background data as may relate to the position for which I am applying. I understand that if selected for an interview, DESE reserves the right to ask questions about my criminal history and that DESE will conduct pre-employment background screenings on final candidates (paid by the Department with the exception of the cost associated with providing a driver's record for applicants with a confidential or out-of-state driver's license). I also agree to provide the necessary information to conduct this background check. Non-criminal background check results will not be released to you by DESE.

    mailto:[email protected]

  • VOLUNTARY AFFIRMATIVE ACTION DATA

    The Missouri Department of Elementary and Secondary Education (DESE) is required to report specific information regarding our applicant pool for affirmative action purposes. The information you provide will be kept confidential in accordance with state and federal laws. Please complete the form and return it to: Human Resources, Missouri Department of Elementary and Secondary Education, P.O. Box 480, Jefferson City, MO 65102-0480.

    The hiring section will not have access to this data during the selection process. The data provided will neither enhance or detract from your opportunity for employment with DESE. This information is requested on a voluntary basis. Refusal to provide this information will not subject you to adverse treatment.

    Title of job for which you are applying: __________________________________________

    Job order number: __________________________________________________________

    1. Ethnic Origin (defined by Office of Federal Compliance Programs, U.S. Department of Labor):

    ❑ White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the MiddleEast, or North Africa.

    ❑ Black or African American (Not Hispanic or Latino) - A person having origins in any of the original blackracial groups of Africa.

    Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or otherSpanish culture or origin regardless of race.

    ❑ Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East,Southeast Asia, or the Indian Subcontinent; for example: Cambodia, China, India, Japan, Korea, Malaysia,Pakistan, the Philippine Islands, Thailand, and Vietnam.

    ❑ American Indian/Native Alaskan (Not Hispanic or Latino) - A person having origins in any of the originalpeoples of North and South America (including Central America), and who maintain tribal affiliation orcommunity attachment.

    ❑ Native Hawaiian/Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoplesof Hawaii, Guam, Samoa, or other Pacific Islands.

    ❑ Two or More Races (Not Hispanic or Latino) - Persons who identify with two or more racial categoriesnamed above.

    2. Gender

    ❑ Male

    ❑ Female

    Missouri Department of Elementary and Secondary Education“Making a positive difference through education and service”

    MO 500-1990 (Rev. 03-17)

    Text Boxemail: [email protected]

    Untitled

    fname: hphone: wphone: eaddress: address: mname: state: zip: legalworker: Offlname: city: perform-functions: Nofull-time: Offpart-time: Offtemp: Offvac-no: minsalary: titleapplying: learnofvacancy: relsindeptyn: Offrelsindept: gedorhsgrad: Offmaxgrade: Offcanstart: schoolnameandloc: oldschool1: schl1crdqtrhrs: schl1crdsemhrs: schl1crdsotr: degree1: major1: oldschool2: schl2crdqtrhrs: schl2crdsemhrs: schl2crdsotr: degree2: major2: oldschool3: schl3crdqtrhrs: schl3crdsemhrs: schl3crdsotr: degree3: major3: oldschool4: schl4crdqtrhrs: schl4crdsemhrs: schl4crdsotr: degree4: major4: testdate: shorthand: Offwpm: wpmshort: officeoperatable: compsoperatablepc: Offcompsoperatablemac: Offcompsoperatableotr: Offotrcomps: softwareused: samsyshr: Offsamsysacc: Offsamsysbud: Offsamsystime: Offvaldrive: Offvalchauffer: Offvalcomdrv: Offvalbusop: Offvalteachcert: Offlicert1: licertno1: licert2: licertno2: valteachcertlist: liccomments: contactsup1: Offempname1: empadd1: jobtitle1: from1: to1: hours1: lastsal1: supnametitle1: phonenum1: supcontact1: duties1: whyleave1: contactsup2: Offempname2: empadd2: jobtitle2: from2: to2: hours2: lastsal2: supnametitle2: phonenum2: supcontact2: duties2: whyleave2: contactsup3: Offempname3: empadd3: jobtitle3: from3: to3: hours3: lastsal3: supnametitle3: phonenum3: supcontact3: duties3: whyleave3: contactsup4: Offempname4: empadd4: jobtitle4: from4: to4: hours4: lastsal4: supnametitle4: phonenum4: supcontact4: duties4: whyleave4: empname5: empadd5: jobtitle5: from5: to5: hours5: lastsal5: supnametitle5: phonenum5: supcontact5: duties5: whyleave5: contactsup5: Offrefname1: refadd1: refdayphone1: refevenphone1: refname2: refadd2: refdayphone2: refevenphone2: refname3: refadd3: refdayphone3: refevenphone3: signdate: type_name: cbox_certify: Offjobapply: jobordno: ethnicw: Offethnicb: Offethnich: Offethnicapi: Offethnicaian: Offgenderm: Offgenderf: OffEmail Form to HR: ethnictmr: Offethnicnhpi: Off