Portal

LaFayette Central School District

5955 U.S. Route 20 West LaFayette, NY 13084

Telephone: 315-677-9728 Fax: 315-677-3372

www.lafayetteschools.org

Employment Application

POSITION PREFERENCE

Teacher Teaching Assistant Administration Clerical Custodial Bus Driver

Substitute Teacher/Teaching Assistant Food Service Worker other (fill in below)

Subject:

Position:

PERSONAL INFORMATION

First Name:*

Last Name:*

Present Mailing Address:*

Phone Number:

City:*

State:*

Zip:*

SS#:*

-

Permanent Mailing Address:

City:

State:

Zip:

Phone Number:

Email:*

Cell Number:

Retirement No.

Yes No

Are you a U.S. Citizen?*

Yes No

Have you filed a declaration of intention to become a citizen?*

Yes No

Have you ever been convicted of a crime?

Explain:*

Have you been fingerprinted to Part 87 of the Regulations of the Commissioner of Education (Criminal/History Record Check for Prospective School Employees & Applicants for Certification?)

Yes No

Yes No N/A

Are you a dishonorably discharged veteran?*

CERTIFICATION/LICENSE (INSTRUCTIONAL STAFF ONLY)

A Subject	B Type*	C Effective Date	D Expiration Date

I hold the New York State Teaching/Teaching Assistant/Administration Certification(s) described below:

* Teachers/Administrators: Provisional, Permanent, Initial, Professional, and Transitional

* Teaching Assistants: Temporary, Continuing, Level I, Level II, Level III, Pre-Professional

Other license(s) held: type and issuing authority:

Please Provide Copies (attach here if possible)

EDUCATIONAL PREPARATION

Name and Location of School

Nature of Studies

Dates of Attendance

Graduate?

From

To

Yes No

EXPERIENCE

List the most recent experience first. Include any substitute or part time and indicate such.

A Dates Employed	B Employer's Name & Address	C Specific Nature of Position	D Reasons for Leaving

TENURE STATUS

Yes No

Were you ever appointed on tenure in a public school district in New York?

Tenure Area

Effective Date

Please complete the following:

Name and address of the school district where tenure was granted:

Were you ever dismissed from the school district conferring tenure pursuant to Education Law section 3020a?

Yes No

REFERENCES

A Name	B Position	C Address and Phone No.

List three individuals having personal knowledge of your professional training, ability, experience and personal character. Include the name, address, and telephone number of your last supervisor who may be contacted for a personal or professional reference.

Yes No

May we contact your present employer?

Yes No

May we contact your former employer?

Placement Folder may be secured from: (Name and Address)

AVAILABILITY

MON TUES WED THURS FRI ALL

Days:

HS BP GS ELEM ONS ALL

Building Preference:

I certify that all statements made by me on this application are true and complete. I understand that any false or misleading statements made by me will be considered justification for disqualification of my application or termination of employment.

Date

Applicant's Signature (use mouse)

Non-Discrimination Policy
The LaFayette Central School District does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs, activities, employment, and admissions; and provides equal access to the Boy Scouts and other designated youth groups.
The following person has been designated to handle inquiries regarding the non-discrimination policies: Jeremy Belfield, Compliance Officer, at jbelfie1d@lafayetteschools.org. 315-677-9728, 5955 US Route 20, LaFayette, NY 13084. Inquiries concerning the application of the LaFayette Central School District non-discrimination policies may also be referred to the U.S. Department of Education, Office for Civil Rights (OCR), 32 Old Slip, 26th Floor, New York, NY 10005, 646-428-3800 (voice) or 800-877-8339 (TIY).

Revised 12/13/2022

Driver's License (School Bus Driver Applicants)

Motorist ID#:*

Class:*

Endorsements:*

State:*

Expiration:*

Restrictions:*

Yes No

Do you currently have a commercial driver permit?*

If Yes, Class?:

Years Licensed:*

Yes

No

Have you ever been convicted of a moving violation or any criminal act during the past three years?*

If Yes, describe:*

Yes

No

Have you had an accident while driving the past 5 years which resulted in injury to yourself or others?*

If Yes, describe:*

Yes No

Have you ever attended Bus Driver Training Course?*

Yes No

Certificate Received?*

Describe training:*

Reference Form Link

For Bus Drivers - Three (3) Unrelated References are required. Using the link on the right, print three copies of the Reference Form, have them completed by each referee and return using the LCSD Document Attachment form located on our website or if you already have them upload using the choose file link.

Please check a position preference.