IF YOU WISH TO APPLY FOR A POSITION WITH OUR SCHOOL DISTRICT, YOU MUST COMPLETE AND RETURN THIS FORM.

The reverse side of this support staff application form must be completed and signed

GOVERNOR WENTWORTH S.A.U. No.49

P.O. Box 190, Wolfeboro Falls, New Hampshire 03896-0190

Telephone (603) 569-1658 Fax (603) 569-6983

DATE: ______________

POSITION BEING APPLIED FOR:_________________________________________________________

Mr.

NAME:Ms. __________________________________________ SOCIAL SEC.#____________________

Mrs.

COMPLETE ADDRESS

(PO Box if you have one)________________________________________________________________

Street Address ________________________________________________________________________

____________________________________________________________________________________

TELEPHONE #:_______________________________________________________________________

EDUCATION SUMMARY:_______________________________________________________________

____________________________________________________________________________________

WORK EXPERIENCE:(Please be specific-years, responsibilities)

____________________________________________________________________________________

What do you consider to be your major qualifications for this position?_____________________________

____________________________________________________________________________________

What do you consider to be the most important responsibilities in this position?______________________

____________________________________________________________________________________

SUBMIT three (3) current written references for persons who can support your qualifications & list below.

Name:________________________________________________ Telephone #:________________

Address:_____________________________________________________________________________

Name:________________________________________________ Telephone #:____________________

Address:_____________________________________________________________________________

Name:________________________________________________ Telephone #:____________________

Address:_____________________________________________________________________________

Please feel free to explain in greater detail any portion of this application.

You may submit special/additional information (i.e., resume)

RETURN APPLICATION TO: The Office of the Superintendent of Schools (at the above address)

SupportApp\forms Revised 10/12/06

YOU MUST SIGN IN BOTH PLACES BELOW

ASSURANCES

My signature certifies:

1. With the exception of a misdemeanor, I have never been convicted of a criminal offense nor have criminal charges pending against me. Further, I certify that I have never been arrested for any offense involving sexual misconduct or moral turpitude.

2. That the facts contained in this application are true and complete to the best of my knowledge and belief. I acknowledge and understand that the superintendent of schools (and/or designee), and the school board will be relying on the information contained in this application, and that the information is complete and accurate. I further understand and agree that, if employed, any falsified statements or any material half-truths, material misstatements or omissions on this application, without full disclosure of all relevant facts, shall be grounds for my immediate dismissal from employment with the school district.

3. That, if hired, I will report to my school principal and/or the superintendent of schools, any suspicions that another employee may be involved in any illegal or immoral acts.

4. I understand that, under New Hampshire state law, no final offer of employment can be made by the Governor Wentworth Regional School District unless and until successful completion of a background check, including a criminal history records check, has been confirmed by the Governor Wentworth Regional School District. Accordingly, I understand and acknowledge that any offer made by the Governor Wentworth Regional School District, its officials, agents, or assigns, whether by formal vote of the Board, written or verbal notification, or other means, is conditional and will become void and be withdrawn if warranted by the results of the criminal history records check.

N.H. RSA 641:3 Unsworn Falsification. A person is guilty of a misdemeanor if:

I. s/he makes a written false statement which s/he does not believe to be true, on or pursuant to a form bearing notification authorized by law to the effect that false statements made therein are punishable; or

II. with a purpose to deceive a public servant in the performance of his official function, s/he

(a) makes any written false statement which s/he does not believe to be true; or

(b) knowingly creates a false impression in a written application for any pecuniary or other benefit by omitting information necessary to prevent statements therein from being misleading; or

(d) submits or invites reliance on any sample, specimen, map, boundary mark, or other object which s/he knows to be false.

III. No person shall be guilty under this section if s/he retracts the falsification before it becomes manifest that the falsification was or would be exposed.

__________________________________________________ _____________

Signature of Applicant Date

RELEASE

I ________________________________________, have applied for a position as a ________________________________ with the Governor Wentworth Regional School District, I hereby grant permission to the Governor Wentworth Regional School District to conduct an investigation of my background, including education, employment, health, credit, reputation, military records, criminal history records and any other factors which the Governor Wentworth Regional School District may deem proper and necessary in order to properly assess my character and background.

I give my permission for any person, business or institution contacted in the course of such investigation to release any and all information properly requested, including the entire contents of my personnel file, and photocopies of the same if requested. I do hereby release such person, business, or institution from all liability for providing correct information. I further release such person, business or institution from any previous agreement, verbal or written, which would prohibit the release of information pertinent to the investigation by the Governor Wentworth Regional School District.

I recognize the right of the Governor Wentworth Regional School District to treat, at its discretion, certain sources as confidential, and its right to withhold from me or my agent the names of such confidential sources, and information obtained therefrom.

__________________________________________________ ____________

Signature of Applicant Date

__________________________________________________ ____________

Signature of Witness Date

Equal Opportunity Employer

SupportApp\Forms Revised 10/12/06