REFERENCES: (List the names of three (3) individuals familiar with your abilities.)
NAME ADDRESS PHONE NUMBER
1.
2.
3.
IT IS THE POLICY OF THE ELMIRA CITY SCHOOL DISTRICT TO PROVIDE FOR AND PROMOTE THE EQUAL
OPPORTUNITY OF EMPLOYMENT, COMPENSATION, AND OTHER TERMS AND CONDITIONS OF EMPLOYMENT
WITHOUT DISCRIMINATION BECAUSE OF AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, SEX, DISABILITY,
MARITAL STATUS OR CRIMINAL RECORD.
INDICATE YOUR ANSWER BY PLACING AN “X” IN THE APPROPRIATE SPACE: YES NO
A. Have you ever been convicted of any crime (felony or misdemeanor)? * _____ _____
- If yes, please give a full explanation.
If you answered “yes” you will not necessarily be disqualified. Each case is evaluated on an individual basis in relation to the duties and
responsibilities of the position for which you have applied. Omit parking or speeding violations assigned a fee of $50.00 or less and any other offense
adjudicated in Juvenile Court or under a Youthful Offender Law.
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STATEMENT: I declare that all statements made in this application are true and complete to the best of my knowledge. I understand that any false
statements made on this application or in interviews will result in immediate rejection or discharge from employment. I authorize the Elmira City
School District to contact schools/college and former employers cited in the statement contained in this application for employment as may be
necessary in arriving at an employment decision. I understand the acceptance of this application for employment by the Elmira City School District
does not constitute or imply a commitment or willingness to offer employment to me in this or any other position. When required, I agree to take a
drug screen testing and comply with fingerprinting and authorize the release of these confidential test results to the Elmira City School District.
DATE: _____________________ SIGNATURE: ______________________________________________________________
Mail to: Elmira City School District * 430 W. Washington Ave * Elmira, NY 14901 or Fax to: 607-735-3009
Administration Building 430 W. Washington Ave Elmira, NY 14901 PHONE (607) 735 – 3000 FAX (607) 735 – 3009