Personal Information

*Full Name	Last Name First Name MIddle Name
Other Names You are Known By
*Social Security Number	- -
*Email
Phone Number(s)
*Present Address
*Present City	State AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
Permanent Address
Permanent City	State AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
*Date Eligible for Employment
Legally Eligible for USA Employment	Yes No
*How did you become aware of this position
Have you been previously employed by ZPSD	Yes No Previous Employment Date
Do you currently have any relatives employed with the Zuni Public School District.  If YES, please list name(s) and their job titles / location.	Yes No Relatives Names
	Licensure Information
New Mexico Teaching Assessment	Yes No      Assessment Date
New Mexico Current License	Yes No   Type of License  Endorsements
Driver License	Yes No Driver License Type
Other Driver License	Yes No Other Driver License Type
	Position Desired
*Job Applying For	1st Choice 2nd Choice 3rd Choice
Please specify club or  activity  for which you are able and willing  to sponsor:
Do you have a Coaching License?	Yes No Coaching License Type Expiration Date
Have you been teaching more than 5 years?	Yes No
Professional Activities (Optional)

*Background

Have you EVER been placed on probation, been convicted of, or pleaded guilty to the commission of a misdemeanor within the last five (5) years?	Yes No
Have you EVER been placed on probation, been convicted of or pleaded guilty to a felony?	Yes No
Are charges pending against you alleging the commission of a Felony or  Misdemeanor?	Yes No
Have you ever been discharged, terminated, non-renewed or asked to resign from any position?	Yes No
Have you ever been guilty of committing any crime against local, state or federal laws?	Yes No
Have you ever been arrested or charged with any crime against any jurisdictional laws?.	Yes No
Are you presently being investigated for any crime or misconduct?	Yes No
Have you ever been reprimanded, disciplined or asked to resign from any position?	Yes No
Have you ever been discharged from any position because of any misconduct?	Yes No
Have you ever resigned from or left employment because of questionable circumstances?	Yes No
Have you ever been investigated for any kind of sexual contact with another person on the job?	Yes No
Have you ever been investigated for questionable activities or mishandling funds?	Yes No
Have you ever been charged or convicted of any sex-related or drug-related offense?	Yes No
Have you ever pled guilty or “no contest” (nolo contendere)  to any crime of any degree?	Yes No
Have you ever been convicted of a crime, other than minor traffic offense?	Yes No

Have you ever been investigated, charge or convicted of any of the following offenses, or crimes?

Aggravated Assualt of a Minor  Yes No	Incest Yes No	Arson Yes No	KIdnapping Yes No
Blackmail Yes No	Misdemeanor Yes No	Burglary/Robbery Yes No	Molestation Yes No
Child Abuse Yes No	Murder Yes No	Commercial Exploitation of a person Yes No	Physical Abuse Yes No
Contributing to the Deliquency of a Minor Yes No	Pornography Yes No	Dangerous Conduct Against Children Yes No	Prostitution Yes No
Sale of Drugs Yes No	Sexual Abuse Yes No	DWI/DUI Yes No	Sexual Assualt Yes No
Felony Offense Yes No	Sexual Contact with a Minor Yes No	Fraud / Embezzlement Yes No	Sexual Exploitation of a Minor Yes No

If you answered Yes to any of the Background Questions above please explain below

References

Reference 1	*Name  Address City State AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
	*Phone *Email Fax
Reference 2	Name  Address City State AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
	Phone Email Fax
Reference 3	Name  Address City State AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
	Phone  Email Fax
Reference 4	Name   Address City State AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
	Phone  Email Fax
Reference 5	Name   Address City State AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
	Phone  Email Fax
*Drivers License or Id Number	Expiration Date Issuing State AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Date Submitted

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