Are you currently receiving Family Independence benefits or food stamps? p Yes p No PLEASE NOTE: A yes answer will not disqualify you from consideration for employment. We must ask this question pursuant to South Carolina law solely for reporting purposes.

GREENWOOD SCHOOL DISTRICT 50 P.O. BOX 248 1855 CALHOUN ROAD GREENWOOD, SOUTH CAROLINA OFFICE OF HUMAN RESOURCES

Directions: Please fill out the front and back of this form with blue or black ink in your own handwriting.

FULL NAME							SOC.SEC. #				DATE
	Last			First	Middle
PRESENT ADDRESS										TELEPHONE
		Street				City		State	Zip
PERMANENT ADDRESS										TELEPHONE
			Street			City		State	Zip

Are you qualified to work in the United States?	Yes	No		FOR EEOC PURPOSES:			Race	Date of Birth
Are you related to any member of the Board of Trustees?			If yes, what relationship?
Have you ever been convicted for violation of any federal or state law?					If yes, state the nature and date of violation.
Do you have any knowledge of a medical professional claim against you that resulted from the performance of or failure to perform professional services?									YES	NO
Position held at present						Present annual salary

Indicate position(s) you are applying for:
	Clerk/Secretary	Aide	Substitute	Lunchroom	Custodian	Maintenance	Bus Driver

Please complete the following information only if you are applying for an office aide, library aide, or clerical/secretarial position. Indicate your knowledge of the following office equipment by using a check mark.
	Typewriter (words per minute	)	Copier	Calculator	Switchboard	Adding Machine	Computer
Type(s) of computer software used:

EDUCATIONAL BACKGROUND

	NAME AND LOCATION OF INSTITUTION	ACADEMIC MAJOR	DATES ATTENDED	DEGREE RECEIVED
High School
City, State
College/University
City, State

PREVIOUS EMPLOYMENT (Include military experience, if any.) List most recent employment first.

Employer Name/Address

Dates of Employment From To

Job Description

Supervisor

May We Contact? Yes No

REFERENCES (Please list three references other than relatives--one should be previous employer).

Name

Address

Telephone

By signing this application, I give permission to Greenwood School District 50 to investigate my past employment and release those persons, schools, companies, or corporations supplying information from all liability and responsibility. I understand that Greenwood School District 50 will request a criminal history record from the South Carolina Law Enforcement Division (SLED) and that any offer of employment is contingent upon receipt of a satisfactory report of criminal history (GCD-R).

Signature

Date

Greenwood School District 50 is committed to the principle of equal opportunity. It is the policy of the District not to discriminate on the basis of race, sex, color, national origin, religion, age, handicap, or disability with regard to its students, employees, or applicants for admission or employment. Please contact the Office of Human Resources or the Office of Administration if you have questions.