Summer Employment Application

Full Name

Home Address

Home Number

Cell Number

Personal E-mail

Social Security Number
Per Florida Statute 119.071(5), this is to notify you of the purpose for collecting and utilizing your Social Security number. Providing your Social Security number is a condition of employment at New Beginnings High School. To protect your identification, we will secure your Social Security number from unauthorized access, and strictly prohibit the release of your Social Security number to unauthorized parties. NBHS collects your Social Security number for legitimate business purposes during the recruitment, selection and hiring process. Once you are employed, your Social Security number will be used for completing state and federally mandated reports and actions that require such, including but not limited to the following: -Cost reporting [237.34 F.S.] -Employment application for determining certification eligibility [1012.56 F.S.] -Completion of federal I-9 form for the filing and issuance of federal employment forms [8 USC 1324a(b)] -Completion of federal W-4 form for filing and issuance of federal employment forms [8 USC 1324a(b)] -Florida Retirement Contribution Report [119.071(5)(a)6.b.] -Conducting criminal background screening [1012.56 F.S.] The procedures for the security, privacy and retention of automated student and staff records shall be in accordance with the requirements of U.S.C 1232g(b)(3), 34 C.F.R. Part 99 and Section 1002.22.F.S.

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I am applying for the following position.

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Reference ***Please DO NOT use a current NBHS employee as a reference in the below section.***

Name

Address

Phone Number

E-mail

Have you ever been an employee of New Beginnings High School or Polk County Public Schools?

Yes No

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Certification / Licenses

If you have an Educator Certification or Professional/Technical License, please provide the following information: (Example: Statement of Eligibility.)

List Certifications/Licensing Coverage(s) on your certificate/license.

State issuing Certificate/License

Validity Dates:(MM/DD/YYYY) to (MM/DD/YYYY)

Type of Certificate/License: Temporary, Professional, Other Certificate/License Number.(Please upload a copy)

If you do not currently hold a valid FLDOE teaching certificate, have you been issued a FLDOE Statement of Status of Eligibility deeming you eligible to hold a valid FLDOE teaching certificate?

Yes No

If you currently hold (or ever held) a Florida Department of Education Teaching Certificate, has action even been taken against your teaching certificate by the Florida Education Practices Commission?

Yes No

Has any State Department of Education or any state or government licensing agency (except a Department of Motor Vehicles License) ever refuse to grant you teaching certification or professional licensure or taken disciplinary action against you or sanctioned your professional license and/or teaching certificate?

Yes No

Are you presently or have ever been under investigation by The Florida Education Practices Commission or any other State Department of Education or Licensing Board ?

Yes No

I___________ insert name below__________ , certify that the answers and statements I have provided to the questions on the summer employment application are true and correct without any falsification, omissions, or misleading statements of any kind whatsoever. I agree that New Beginnings High School shall not be held liable in any respect if I am not employed or if my employment is terminated because of false, misleading statements, answers or omissions made by me in the application.

Name/Signature

Date signed

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CRIMINAL RECORD INFORMATION ALL APPLICANTS PLEASE READ VERY CAREFULLY Under provisions in Florida Statutes 943.0585 and 943.059, the entire arrest record is revealed to school districts by the Florida Department of Law Enforcement and the FBI when fingerprintings are supplied, including “sealed records” and “expunged records.” Therefore you are required to reveal such information on this application.

Notice to Applicants You must provide all information requested, regardless of whether your criminal record has been sealed in any part. Florida Law allows the school board access to seal and/or all other criminal records. Information disclosed pursuant to this section will be evaluated on any individualized basis, taking into account the nature of the offence and underlying conduct, the relevance of the offense to the employment position(s) for which you are applying, the proximity in time of the occurrence of the offense in relation to this application, and other relevant factors. However, your failure to disclose any request information will, in the absence of extraordinary, mitigating circumstances, result in the rejection of your application or, if the non-disclosure is discovered after your hire, the termination of your employment.

Have you ever been arrested or charged for a criminal offense other than a mirror traffic violation ? (DUI is NOT considered a minor traffic violation.)

Yes No

Is there any criminal charge now pending against you other than a minor traffic violation ? (DUI is NOT considered a minor traffic violation.)

Yes No

Are you currently on probation or currently under any imposed requirements for charge other than a minor traffic violation ? (DUI is NOT considered a minor traffic violation.)

Yes No

If Yes to any of the above, give detail about the date, nature of charge(s), and disposition of charge(s).

I certify that the answers given by me to the foregoing questions and statements are true and correct without falsifications, omissions, or misleading statements of any kind whatsoever. I agree that New Beginnings High School shall not be held liable in any respect if I am not employed or if my employment is terminated because of false or misleading statements or answers or omissions made by me in this application.

Name/Signature

Date Signed