Application for Employment

If you are interested in a position at Dr. Lewis Dolphin Stallworth, Sr., Charter Schools, Inc. (DLDSSCSI), please complete the following form. We will contact you for further information. Thank you.

* Required Fields

Name

First Last

Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Position Applying For

*Are you at least 18 years of age?(Required)

Yes

*Do you have a valid driver's license?(Required)

Yes

If not a citizen, do you have legal right to remain in the U.S.?

Yes

*Do you have the legal right to work in the U.S.?(Required)

Yes

*Are you employed now?(Required)

Yes

*If so, may we contact your employer?(Required)

Yes

Education

High School Name & Location

High School Graduate?

Yes

College Name & Location

College Years Attended

College Graduate?

Yes

Trade School Name & Location

Trade School Years Attended

Trade School Graduate?

Yes

Employment Desired

Are you applying for

Non-Teaching Staff/Full-Time

Teaching Staff

Temporary or Part-Time

What days and hours are you available for work?

Why are you applying for work at Stallworth Charter Schools?

Do you have a reliable means of transportation to and from work?

Yes

*Can you present proof of US citizenship/right to work?(Required)

Yes

Essential Functions

Are you able to perform the essential functions of the job for which you are applying either with or without reasonable accommodation? Please select yes/no to answer the essential functions question.

Yes

Have you ever applied or worked for DLDSSCSI before?

Yes

If yes, when?

Do you have any friends or relatives working for DLDSSCSI?

Yes

If yes, state name(s) and relationship

Are you related to anyone working for the Stockton USD?

Yes

Have you ever been investigated by any school districts?

Yes

If "yes" to EITHER of the last two questions, please explain

*Convicted of a criminal office, felony, or misdemeanor?(Required)

Yes

Criminal Offense, Felony, or Misdemeanor If yes, state below the nature of the crime(s), when and where convicted, and the disposition of the case. A criminal clearance is required for any employee who has contact with our students. We will do a background check and Live Scan fingerprinting on all prospective employees. (Conviction of a criminal offense will not necessarily bar you from employment here. By law, your fingerprints must be submitted to the Federal Bureau of Investigation. If you disclose offenses on this application form, special consideration can be given to their nature and circumstances. Failure to make full disclosure will cause DLDSSCSI to require your immediate termination of employment).

Employment History

List all employment of the past five years, starting with the most recent. Please complete the following section even if attaching a resume.

Resume (optional)

Max. file size: 125 MB.

Employment Section #1

Name of Employer

Address (street, city, state, and zip)

Type of Business

Supervisor's Name

Telephone Number

Your Position and Duties

Date of Employment (from mm/dd/yy to mm/dd/yy)

Salary/Wage (starting and ending)

Reason for Leaving

May we contact your employer?

Yes

Employment Section #2

Name of Employer

Address (street, city, state, and zip)

Type of Business

Telephone Number

Supervisor's Name

Your Position and Duties

Date of Employment (from mm/dd/yy to mm/dd/yy)

Salary/Wage (starting and ending)

Reason for Leaving

May we contact your employer?

Yes

Employment Section #3

Name of Employer

Address (street, city, state, and zip)

Type of Business

Supervisor's Name

Telephone Number

Your Position and Duties

Date of Employment (from mm/dd/yy to mm/dd/yy)

Salary/Wage (starting and ending)

Reason for Leaving

May we contact your employer?

Yes

References

Please provide the names of three persons not related to you whom you have known for a minimum of one year, and be sure to include phone numbers.

1. Name and Relationship

Address

Phone Number

2. Name and Relationship

Address

Phone Number

3. Name and Relationship

Address

Phone Number

Withholding Information Certification I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material facts on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

*Please certify the above statement with your initials(Required)

Authorize Investigation I hereby authorize investigation of all statements and records contained in this application and I authorize all references I have listed to disclose to DLDSSCSI any and all information related to my work records without giving me prior notice of such disclosure. In addition, I hereby release DLDSSCSI, my former employers and all other persons, corporations, partnerships, and associations from any and all claims arising out of or in any way related to such investigation or disclosure.

*Indicate your permission to above statement with your initials(Required)

At-Will Employment Further, I understand and agree that my employment is at-will and for no definite period and may be terminated at any time without previous notice at the option of Dr. Lewis D. Stallworth, Sr. Charter School or myself, and that no promises or representation contrary to the foregoing are binding on DLDSSCSI unless made in writing and signed by me and the agency's representative. I agree to abide by the rules the DLDSSCSI set forth in the Policies and Staff Manual. I agree to submit to an authenticated fingerprint card, evidence of good health, T.B. test result before reporting for work.

*Please certify the above statement with your initials(Required)

*Signature (Please enter your full name)(Required)

*Date (mm/dd/yy)(Required)

MM slash DD slash YYYY

Happy teacher working with young students at a round table