Application for Employment

Please print legibly and complete all sections, indicating "n/a" if the information requested is not applicable.

Personal Data
*Name (last, first, middle):
Email Address
Present Address:
*Number and Street:
*City:
*State:
*Zip:
*How long have you resided there?
Previous Address:
Number and Street:
City:
State:
Zip:
How long have you resided there?
*Telephone Number:
*Are you over the age of 18?	Yes No
If no, employment is subject to verification that you are of minimum legal age:
Employment Objective
*Position Desired:
*Salary Desired:
*Location:
General Information
*How were you referred to us?
If you were referred by an employee, please list their name and location:
*Have you ever been employed by Imagine Schools, Inc., Chancellor Beacon Academies, Inc., Chancellor Academies, Inc., Beacon Education Management and/or JCR and Associates?	Yes No
If yes, please list dates of employment.
From:
To:
*Have you ever been employed under any name other than the one stated in this application?	Yes No
If yes, please provide the other name(s):
*Do you have any relatives or friends employed by Imagine Schools?	Yes No
If yes, please provide their name, relationship and location of employment:
*Are you presently employed?	Yes No
If yes, what notice will be required?
*What date will you be available for employment?
*Have you ever been involuntary terminated, not re-appointed or asked to resign from a previous job?	Yes No
If yes, please explain:
Certification
*Do you hold an Educator's Certificate?	Yes No
If yes, please provide the following:
Certification Type 1:
Certificate Number 1:
Valid from 1:
Valid to 1:
Issuing State 1:
Subject, area or coverage 1:
Certification Type 2:
Certificate Number 2:
Valid from 2:
Valid to 2:
Issuing State 2:
Subject, area or coverage 2:
If you do not hold an Educator's Certificate, are you eligible to receive one?	Yes No
Please explain:
*Have you ever had an Educator's Certificate suspended, revoked or not re-issued?	Yes No
If yes, please explain:
Education Record
*High School Address (City/State):
*High School Years Completed:	1 2 3 4
*High School Major Field of Study:
*High School Graduated:	Yes No
*High School Degree:
College 1 Address (City/State):
College 1 Years Completed:	1 2 3 4
College 1 Major Field of Study:
College 1 Graduated:	Yes No
College 1 Degree:
College 2 Address (City/State):
College 2 Years Completed:	1 2 3 4
College 2 Major Field of Study:
College 2 Graduated:	Yes No
College 2 Degree:
Graduate School Address (City/State):
Graduate School Years Completed:	1 2 3 4
Graduate School Major Field of Study:
Graduate School Graduated:	Yes No
Graduate School Degree:
Trade/Correspondence School Address (City/State):
Trade/Correspondence School Years Completed:	1 2 3 4
Trade/Correspondence School Major Field of Study:
Trade/Correspondence School Graduated:	Yes No
Trade/Correspondence School Degree:
Other Address (City/State):
Other Years Completed:	1 2 3 4
Other Major Field of Study:
Other Graduated:	Yes No
Other Degree:
*List academic honors, scholarships, and honorary fraternities:
*List hobbies and outside interests:
*Do you plan to continue your education?	Yes No
If yes, please specifiy:
Foreign Languages
Language 1:
Indicate degree of fluency 1:	Read Write Speak
Language 2:
Indicate degree of fluency 2:	Read Write Speak
Business Skills
*Typing Speed:
*Word Processing:
*Shorthand:
*Dictaphone:
*Computer Hardware/Software:
Other Business Equipment:
*List any professional licenses you hold other than teaching certificates:
*List any professional organizations you belong to:
Military Service
Branch:
Highest Rank Attained:
Dates of Service:
Special Training:
Did you receive anything other than an honorable discharge?
Driving Record Answer these questions if driving is part of the duties and responsiblities of the job for which you are applying.
*Do you have a valid Driver's License?	Yes No
*Issuing State:
*Driver's License Number:
*Expiration Date:
*Any restriction(s) on your license?	Yes No
If yes, please explain:
Criminal Record Answering "yes" to these questions does not constitute an automatic bar of employment. Only those crimes which are substantially related to the position you are seeking will be considered.
*Have you ever been convicted, pled no contest, been placed on probation, enrolled in a pre-trial diversion program, or had adjudication withheld in a criminal offense, felony, misdemeanor or otherwise?	Yes No
If yes, please give dates and details for each instance:
*Do you have any criminal charges currently pending?	Yes No
If yes, please explain:
Employment History (complete in full - do not attach a resume) Please list below all present and past employment since graduation, including at least three past employers, for the last ten years.
Dates of Employment 1:
Total Month 1:
Reason for Leaving 1:
Name of Employer 1:
Type of Business 1:
Address/City/State/Zip 1:
Phone 1:
Starting Position 1:
Supervisor's Name, Title & Phone 1:
Starting Salary 1:
Most Recent Position 1:
Supervisor's Name, Title & Phone 1:
Ending Salary 1:
May we contact? 1:	Yes No
If not, why not? 1:
Give full description of responsibilities and duties 1:
Dates of Employment 2:
Total Month 2:
Reason for Leaving 2:
Name of Employer 2:
Type of Business 2:
Address/City/State/Zip 2:
Phone 2:
Starting Position 2:
Supervisor's Name, Title & Phone 2:
Starting Salary 2:
Most Recent Position 2:
Supervisor's Name, Title & Phone 2:
Ending Salary 2:
May we contact? 2:	Yes No
If not, why not? 2:
Give full description of responsibilities and duties 2:
Dates of Employment 3:
Total Month 3:
Reason for Leaving 3:
Name of Employer 3:
Type of Business 3:
Address/City/State/Zip 3:
Phone 3:
Starting Position 3:
Supervisor's Name, Title & Phone 3:
Starting Salary 3:
Most Recent Position 3:
Supervisor's Name, Title & Phone 3:
Ending Salary 3:
May we contact? 3:	Yes No
If not, why not? 3:
Give full description of responsibilities and duties 3:
Please explain any gaps in your employment history:
Previous Experience
*Please describe any previous experience that you have in the position for which you are applying, or in any similar or related position:
References Please list three (3) individuals not related to you, whom you have known for at least one year, and who have observed your work performance (supervisors or employers, not co-workers).
Name 1:
Relationship 1:
Occupation 1:
Phone Number 1:
Years Known 1:
Name 2:
Relationship 2:
Occupation 2:
Phone Number 2:
Years Known 2:
Name 3:
Relationship 3:
Occupation 3:
Phone Number 3:
Years Known 3:
Name 4:
Relationship 4:
Occupation 4:
Phone Number 4:
Years Known 4:
Emergency Contact In case of accident or other emergency, whom should we contact?
*Name:
*Relationship:
*Home Phone:
*Cell Phone:
*Address (Number and Street):
*City:
*State:
*Zip:
*Place of Work (including address):
*Work Phone:
We are an Equal Opportunity Employer APPLICANT'S STATEMENT By my signature below, I certify that all information that I have provided on this application, under separate cover and in any interview, as part of the application process, is true, complete and accurate. I understand that any false statements, omissions or misleading statements will be grounds to not hire me, and if discovered after employment, may subject me to dismissal. I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of my wages. I further understand that I have the right to terminate my employment at any time, with or without notice or reason, and the Company/School has the same right. No one other than the CEO of the Company has authority to modify this relationship or make any agreement to the contrary. Any such modificaiton or agreement must be in writing. I understand that Imagine Schools, Inc. reserves the right to require me to submit to a drug test at any time and also reserves the right to require me to submit to an alcohol test and/or medical examination to the extent permitted by law. I further understand that the school may contact previous employers and I authorize those employers to disclose to the Company all records and other information pertinent to my employment with them. I release my previous employers from any liability as a result of their disclosure of information about me to the Company. I also authorize the Company to provide truthful information concerning my employment with it to my future prospective employers and I agree to hold it harmless for providing such information. I understand the Company may obtain a consumer report or reports on me. I authorize Imagine Schools, Inc. and its representatives and agents to obtain such a report or reports for use in connection with my application for employment and for other employment-related reasons. If hired, this authorization shall remain on file and serve as ongoing authorization for procurement of employment-related consumer reports at any time during my employment. I understand the term "consumer report" includes, but is not limited to, credit checks, criminal background checks, department of motor vehicle reports, and investigative consumer reports. By submitting this form, I certify that I have read and understand this statement. DO NOT SUBMIT until you have read and understand this statement.