BERKSHIRE HILLS REGIONAL SCHOOL DISTRICT

Great Barrington - Stockbridge - West Stockbridge

P.O. Box 617 – 50 Main Street, Stockbridge, MA 01262

413-298-4017 Ext. 19

APPLICATION (Custodians, Secretaries/Clerks/Aides, Substitutes)

POSITION BEING APPLIED FOR______________________________DATE:_______________

WHEN WOULD YOU BE AVAILABLE FOR WORK: ___________________________________

PERSON TO NOTIFY

IN CASE OF EMERGENCY

_____________________________________ _______________________________________

NAME OF APPLICANT: NAME:

_____________________________________ ________________________________________

ADDRESS: ADDRESS:

_____________________________________ ________________________________________

CITY/STATE ZIP CITY/STATE ZIP

_____________________________________ ________________________________________

TELEPHONE NUMBER: TELEPHONE NUMBER:

_____________________________________

SOCIAL SECURITY NUMBER:

Rate of Pay Expected______________________ Would you work full time ______________________

Would you work part time _________________________

Days________________ Hours_____________________

Can you, if selected for employment, submit a birth certificate and/or other proof of age?

If no, please explain: _____________________________________________________________________________

_____________________________________________________________________________

Is any additional information relative to change of name, use of assumed name or nickname necessary to enable a check of your prior employment and/or records?

If yes, please explain: ___________________________________________________________________________

Have you ever been convicted of any crime other than a minor traffic violation? If yes, state where, when and disposition of case _____________________________________________________________________________

_____________________________________________________________________________

Please describe any special experience, skills, or qualifications which you feel would especially fit you for work with the District_______________________________________________________

“THE BERKSHIRE HILL REGIONAL SCHOOL DISTRICT DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, SEX, SEXUAL ORIENTATION, RELIGION, NATIONAL ORIGIN OR DISABILITIES."

(Chapter 622, Title IX and Sec. 504 Regs.)

RECORD OF EMPLOYMENT

(Begin with current or most recent employment)

From: To: Start Finish Reason for

Name & Address of Employer Mo/Yr Mo/Yr Position Salary Salary Leaving

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

RECORD OF EDUCATION

Course Dates Attended Last Year Degree/

Name & Address of School Of Study From To Completed Graduate Diploma

High: _________________________________________________________________________________

College: _______________________________________________________________________________

Other: _________________________________________________________________________________

REFERENCES

1. List three individuals qualified to give information noting your capabilities for the position you seek.

Name Position and Telephone Number

1. ________________________________________________________________________________

2. ________________________________________________________________________________

3. ________________________________________________________________________________

2. In addition to the above references, submit or forward 3 current letters of reference.

PRIOR TO BEING HIRED FOR A POSTION, APPLICANTS MUST PROVIDE

Completed CORI (Criminal Offender Record Information) Form

An offer of employment may be conditioned on the results of a medical examination conducted solely for the purpose of determining whether the applicant is capable of performing the essential functions of the position.

I certify that the above information is correct _______________________________________

I understand that any misstatement or omission Type or Print Name

of a material fact in this application may be _______________________________________

cause for rejection of this application or my Signature

dismissal from employment. _______________________________________

Date

INTERVIEWER’S COMMENTS

________________________________________________________________________________________

________________________________________________________________________________________

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