ࡱ> M &bjbj== WW!l4 h(h(h(h((< F~4+4+4+4+4+ . . .`FbFbFbFbFbFbF$_H JF .-^ . . .F/44+4+yF/4/4/4 .84+4+`F/4 .`F/4/4 <l<<4+(+ \< H$h(.<< F0F<Kg1K</4    An Equal Opportunity Employer EEO Information Not for Interview Purposes In accordance with Equal Employment laws, we are required to maintain statistical data on all applicants. We ask for your cooperation in completing and returning the following information. This form will be separated from your application and not used in the screening or interviewing processes. NameDate of BirthAddressTelephone NumberDrivers License NumberState Where IssuedSex:Female MaleRace/Ethnic Group:American Indian Asian / Pacific Islander HispanicBlack White Other (specify) ______________Position Applied For: I hereby authorize any city, county, state or federal agency, department or bureau to release any information in their files under the above name. I understand and realize that the information so released may prove unfavorable to me. I agree to hold any source of information blameless for any error in reporting this information. I further release all personnel whomever from any liability from any liability arising out of or resulting from the release of this information. Signature of Applicant: Date: If you are a disabled veteran or have a physical or mental disability, you are invited to volunteer this information. The purpose is to provide information regarding proper placement and appropriate accommodation to enable you to perform the job in a proper and safe manner. This information will not adversely affect any consideration you may receive for employment. If you wish to be identified, sign here: Check the box that describes your status: ( Disabled Veteran ( Vietnam Veteran ( Disabled Individual Please Do Not Write Below This Line Background Check Results: Warrant:( No Warrant Found( Active Warrant Indicated________________________________________________________________________________Local Record:( No Record Found( Prior Record (Please Attach)________________________________________________________________________________DL#:( Status Clear( Status Suspended________________________________________________________________________________Signature of Person Conducting Check:   APPLICATION FOR EMPLOYMENT  An Equal Opportunity Employer This application must be completed in full and signed. Incomplete or unsigned applications will not be considered. You are neither guaranteed an interview nor a job by filling out this application. The Cesar Chavez Public Charter Schools for Public Policy are an employment-at-will company, and therefore, has no permanent employees. If you are selected for an interview, the Human Resources department will notify you. The Csar Chvez Public Charter Schools for Public Policy 709 12th Street, SE Washington, DC 20003 Telephone: 202.547.3975 Email: recruitment@chavezschools.org Last NameFirst NameMiddle NameTelephone Number(s)AddressCityStateZip CodePosition Applied For: (one position per application)Date of ApplicationReferral SourceAdvertisement JobLineInternet Job ServiceChavez Employee Walk-InOther (specify below) ___________________________________________ Are you currently a Chvez Schools employee? ( Yes ( No If yes, please specify dept. Are you able to provide proof that you are authorized to work in the United States? ( Yes ( No Have you been employed here before? ( Yes ( No If yes, Position Dates Do you have any relatives employed here? ( Yes ( No If yes, Name Department Relation Have you been convicted of a felony? ( Yes ( No If yes, please specify date(s) and nature of offense(s): AVAILABILITY Date available to begin work: ___________________________________ EDUCATION Beginning with High School, provide information on all schools attended including colleges, special courses and trade schools. Name and Location of SchoolDid you Graduate?Name of Degree or Certificate Major/Minor( Yes ( No( Yes ( No( Yes ( No EMPLOYMENT EXPERIENCE Please list your current and past jobs, starting with your present or most recent job. Include any military experience. A resume may be attached but does not take the place of this form. If you need more space, please use the Additional Employment Experience section on the next page of this application. May we contact your present employer? ( Yes ( No Company NameTelephone ( )Dates Employed From ToAddressNumber of Hours Worked Per WeekJob TitleName of SupervisorHourly Rate Start LastDescribe Duties:Reason for LeavingCompany NameTelephone ( )Dates Employed From ToAddressNumber of Hours Worked Per WeekJob TitleName of SupervisorHourly Rate Start LastDescribe Duties:Reason for LeavingCompany NameTelephone ( )Dates Employed From ToAddressNumber of Hours Worked Per WeekJob TitleName of SupervisorHourly Rate Start LastDescribe Duties:Reason for LeavingCompany NameTelephone ( )Dates Employed From ToAddressNumber of Hours Worked Per WeekJob TitleName of SupervisorHourly Rate Start LastDescribe Duties:Reason for Leaving REFERENCES Provide the names of three work-related references other than relatives: NameAddressPhone NumberRelationshipYearsYOU MUST SIGN THIS APPLICATION. READ THE FOLLOWING CAREFULLY BEFORE YOU SIGN. I certify that all answers given herein are true and complete to the best of my knowledge. I authorize any reference checks as well as the investigation of all statements contained in this application for employment that may be necessary in arriving at an employment decision (this process includes background checks). In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. If selected for employment, I further understand that my employment is contingent upon passing a background investigation and that I may be asked to submit to an employment physical and random drug testing.. I also understand that, if hired, I will be required to abide by all rules and regulations of the Chvez Schools. Signature of Applicant Date The Csar Chvez Schools are an equal opportunity education institution and will not on the basis of race, color, national origin, gender, sexual orientation, age, disability or any other capacity protected by law discriminate in its admission to or employment in its educational programs or activities as required by Title II of the ADA, Title VI, Title IX, and Section 504. If you believe you have been discriminated against for these reasons on consideration of your application, please notify Mitzi Burby, Title IX Coordinator of the Chvez Schools at 709 12th Street, SE, Washington, DC 10003, phone: 202.547.3975; fax: 202.547.3449; email: mitzi.burby@chavezschools.org. It is also your right to notify the Equal Employment Opportunity Commission, Office of Federal Contract Compliance Programs, or any appropriate local or state agency of your complaint.  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