CERTIFIED employment application PACKET
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CERTIFIED employment application PACKET
Mescalero Apache School
Human Resource Office
P.O. Box 230
Mescalero, NM 88340
Phone (575) 464-4431
Fax (575) 464-0053
name ___________________________________________________________________
MAILING ADDRESS __________________________________________________
___________________________________________________________________________
Telephone # _________________________________________________________
EMAIL: _________________________________________________________________
To the Applicant: Please read the following and sign below:
1.
The Mescalero Apache School is an equal opportunity employer and does not discriminate on the basis
of race, sex, color, national origin, religion, or disability.
2.
You must complete this Application Packet in full and provide all information requested including
the following:
Application/Questionnaire for Certified Employment and Resume
Official College/University Transcripts
Current New Mexico License (ie., Teaching, Administrative, Counseling, Coaching, etc.)
Current New Mexico License (ie. Speech Therapist, Social Worker, Occupational Therapist, etc.)
3 Current Signed Letters of Reference
Authorization for Release of Information
An incomplete application packet will not be considered.
3.
The provision of any false, incomplete, or misleading statements in this application packet, on any other
documents submitted with it, or as part of any other phase of the application process, will result in the
applicant’s disqualification or discharge, regardless of when the misrepresentation or omission is
discovered.
4.
Applicants are subject to employment and education history checks, drug testing, AND background
investigations, including mandatory fingerprinting, as a condition of the application process for
employment consideration.
5.
All offers of employment are contingent upon the satisfactory completion of background investigations.
Criminal convictions shall not automatically bar an applicant from obtaining employment with the school,
but pursuant to the Crime Control Act of 1990 and Public Law 101-630 (Indian Child Protection
and Family Violence Prevention Act), may be basis for refusing employment.
I have read and understood the foregoing: __________________________________________
Applicant’s Signature
P.O. Box 230 ~ 249 White Mountain Drive
Mescalero, NM 88340
Phone: (575) 464-4431 Fax: (575) 464-0053
Information contained in this application/questionnaire is for official use only.
APPLICATION/QUESTIONNAIRE FOR CERTIFIED EMPLOYMENT
Notice to Applicant: The Crime Control Act of 1990, Public Law 101-647 (codified in 42 United States Code § 13041), requires that employment
applications for child care positions have applicants sign a receipt of notice that a criminal record check will be conducted as a condition of
employment.
POSITON DESIRED
First Choice
___________________________________________________________________________
Second Choice ___________________________________________________________________________
Third Choice
1. Full Name
Last Name
___________________________________________________________________________
First Name
Middle Name
Jr., II, etc.
3. Other Names Used – Maiden name, from a former marriage, alias(s), or nickname(s).
Name
5. Place of Birth
City
County
2. Date of Birth
Month
Day
Year
4. Telephone Number
(
)
6. Social Security Number
State
7. Residence – List where you have lived; beginning with the most recent and working back 5 years. All periods in the last
5 years must be accounted for in you list.
Month/Year
Month/Year
**Incomplete information will disqualify you from further consideration**
Street Address
City
State
Zip Code
1)
To Present
Month/Year
Month/Year
Street Address
City
State
Zip Code
2)
To
Month/Year
Month/Year
Street Address
City
State
Zip Code
3)
To
Month/Year
Month/Year
Street Address
City
State
Zip Code
4)
To
Month/Year
Month/Year
Street Address
City
State
Zip Code
5)
To
7. a. Residence on an Indian Reservation – List any Indian Reservations in which you have lived or worked in the last 5 years.
Name of Indian Reservation
Last Name
Application/Questionnaire Continued
First Name
Middle Initial
Jr., II, etc.
Social Security Number
8. Education – List the schools you have attended.
High School
Address, City, State, Zip Code
Date Graduated
Diploma / GED Received
College/University
Address, City, State, Zip Code
Date Graduated
Degree / Diploma / Other Received
College/University
Address, City, State, Zip Code
Date Graduated
Degree / Diploma / Other Received
College/University
Address, City, State, Zip Code
Date Graduated
Degree / Diploma / Other Received
College/University
Address, City, State, Zip Code
Date Graduated
Degree / Diploma / Other Received
8. a. Graduate Hours Completed
Beyond Bachelor Degree
Beyond Master Degree
8. b. Certification – List all licenses ie. Teaching, Administrative, Counseling, Coaching, Social Worker, Speech Therapist,
Educational Diagnostician, Occupational Therapist, etc. Please use a separate sheet if necessary.
State
Level
Type
Endorsements
State
Level
Type
Endorsements
9. Teacher Application Supplement
The Mescalero Apache School is located on the Mescalero Apache Reservation in South Eastern New Mexico. Please state your qualifications for working with
a predominately Mescalero Apache student enrollment:
Outline some of the things you will do as a teacher which will allow you to establish a harmonious relationship with the students.
Explain how your own personal values will be reflected in your teaching.
Comment on MOTIVATION
Comment on CLASSROOM MANAGEMENT
Comment on PLANNING
Application/Questionnaire Continued
First Name
Middle Initial
Last Name
Jr., II, etc.
Social Security Number
10. Employment – List your employment activities, beginning with the present and working back. Each year must be accounted
for without breaks. For periods of unemployment, list dates and “unemployed” or “attending school.”
Month/Year
**Incomplete information will disqualify you from further consideration**
Month/Year
Employer Name
Position Title
1)
To
Employer Address
City
Supervisor’s Name
Telephone Number
(
Reason For Leaving
Month/Year
Month/Year
Employer Name
(
Month/Year
Month/Year
(
Month/Year
Reason For Leaving
Telephone Number
)
Position Title
State
Other Employer Reference
Zip Code
Telephone Number
)
(
Employer Name
)
Position Title
City
Telephone Number
(
Zip Code
(
Employer Name
5)
To
Employer Address
Supervisor’s Name
Other Employer Reference
)
Telephone Number
Reason For Leaving
)
State
City
Supervisor’s Name
Telephone Number
Position Title
Telephone Number
(
Zip Code
(
Employer Name
4)
To
Employer Address
Month/Year
Other Employer Reference
City
Reason for Leaving
)
State
)
3)
To
Employer Address
Supervisor’s Name
Telephone Number
Position Title
Telephone Number
Reason For Leaving
Zip Code
(
City
Supervisor’s Name
Month/Year
Other Employer Reference
)
2)
To
Employer Address
Month/Year
State
)
State
Other Employer Reference
Zip Code
Telephone Number
(
)
Last Name
Application/Questionnaire Continued
First Name
Middle Initial
Jr., II, etc.
Social Security Number
11. Professional References – List 5 people who have known you Professionally for at least 5 years.
1) Name
Address
2) Name
Address
3) Name
Address
4) Name
Address
5) Name
Address
Do not include relatives or anyone who is listed elsewhere on this application.
Month /Year
Dates Known
Month/Year
To
Telephone Number
□ Day
□ Night ( )
State
Zip Code
Dates Known
Month/Year
To
Telephone Number
□ Day
□ Night ( )
State
Zip Code
Dates Known
Month/Year
To
Telephone Number
□ Day
□ Night ( )
State
Zip Code
Dates Known
Month/Year
To
Telephone Number
□ Day
□ Night ( )
State
Zip Code
Dates Known
Month/Year
To
Telephone Number
□ Day
□ Night ( )
State
Zip Code
City
Month /Year
City
Month /Year
City
Month /Year
City
Month /Year
City
Please continue on next page
Last Name
Application/Questionnaire Continued
First Name
Middle Initial
Jr., II, etc.
Social Security Number
12. Background Information – For all questions, provide all additional required information in the space provided or on a
separate sheet. Ensure full name and social security number is on any attachments to this
application.
**Incomplete information will disqualify you from further consideration**
12. a. Have you been arrested for, charged with, or convicted of, been imprisoned, been on probation, or been on parole
YES
for any offense(s)? Include all offenses where you have been found guilty, pled guilty or nolo contendere (no contest).
(Leave out traffic fines of less than $150.00.)
NO
If “YES”, use item 12.i. to provide the date, explanation of violation, place of occurrence, and the name and address of the
police department or court involved.
12. b. Have you been convicted by a military court-martial?
YES
NO
If “YES”, use item 12.i. to provide the date, explanation of the violation, place of occurrence, and the name and address of
the military authority or court involved.
12.c. Are you now under charges for any violation of law?
YES
NO
YES
NO
YES
NO
If “YES”, use item 12.i. to provide the date, explanation of the violation, to include a description of what led to your arrest,
disposition of the arrest(s) or charge(s) and attach a copy of the police report and nay related court documents.
12. f. Have you ever been found guilty of, or entered a plea of nolo contendere (no contest) or guilty to , any felonious
offense, or any of two or more misdemeanor offenses under Federal, State, or Tribal Law involving crimes of violence, sexual
assault, molestation, exploitation, contact or prostitution, crimes against persons; or offenses committed against children?
YES
NO
If “YES”, use item 12.i. to provide the date, explanation of the violation, disposition of the arrest(s) or charge(s), place of
occurrence, and the name and address of the police department or court involved.
12. g. Have you illegally used any controlled substance, for example, marijuana, cocaine, crack cocaine, hashish, narcotics
(opium, morphine, codeine, heroin, etc.), amphetamines, depressants (barbiturates, methaqualone, tranquilizers, etc.),
hallucinogenics (LSD, PCP, etc.), or illegally used prescription drugs?
YES
NO
YES
NO
If “YES”, use item 12.i. to provide the date, explanation of violation, place of occurrence, and the name and address of the
police department or court involved.
12.d. Have you been fired from any job for any reason, did you quit after being told that you would be fired, or did you leave
any job by mutual agreement because of specific problems?
If “YES”’ use item 12.i. to provide the date, an explanation of the problem, reason for leaving, and the employer’s name and
address.
12. e. Have you ever been arrested for or charged with a crime involving a child?
If “YES”, use item 12.i. to provide the date(s) of use, identify the controlled substance(s) and/or prescription drugs used, and
the number of times each was used. Include any treatment or counseling received.
12. h. Have you been involved in the illegal purchase, manufacture, trafficking, production, transfer, shipping, receiving, or
sake of any narcotic, depressant, stimulant, hallucinogen, or cannabis, for your own intended profit or that of another?
If “YES”, use item 12.i. to provide information relating to the type of substance(s), the nature of the activity, and nay other
details relating to your involvement with illegal drugs.
12. i. Use this space or attach additional sheets to provide explanations of any questions you may have answered “YES” to.
Certification that my Answers are True
My statements on this application/questionnaire, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are
made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this application or its attachments may be grounds for
not hiring me, or firing me after I begin work, and may be punishable by fine or imprisonment.
____________________________________________________
Applicant’s Initials
Date
I certify that my responses to the above questions are made under penalty of perjury, which is punishable by fine or imprisonment, and that I have received
notice that a criminal history records check will be conducted and is a condition of employment. I understand my right to obtain a copy of any criminal history
report made available to the Mescalero Apache School and my rights to challenge the accuracy and completeness of any information contained in the report.
__________________________________________________________________________________________________________________
Applicant’s Printed Name
Applicant’s Signature
Date
P.O. Box 230 ~ 249 White Mountain Drive
Mescalero, NM 88340
Phone: (575) 464-4431 Fax: (575) 464-0053
AUTHORIZATION fOR RELEASE OF INFORMATION
Information contained in this Release is for official use only.
I authorize any investigator, or other duly accredited representative of the agency conducting my background
investigation, to obtain any information relating to my activities from individuals, schools, residential management
agents, employers, criminal justice agencies, or other sources of information. This information may include, but is not
limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, and
criminal history record information.
I, further authorize any investigator, or other duly accredited representative of the Mescalero Apache School, who is
conducting my background investigation, to request criminal record information about me from criminal justice agencies
for the purpose of determining my eligibility for assignment to, or retention in a position working with children. I
understand that I may request a copy of such records as may be available to me under the law.
I authorize custodians of records and other sources of information pertaining to me to release such information upon
request of the investigator, or other duly accredited representative authorized above regardless of any previous
agreement to the contrary.
I understand that the information released by records custodians and sources of information is for official use by the
Mescalero Apache School only for purposes of determining my suitability for employment with the Mescalero Apache
School.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization
is valid from the date signed until termination of my affiliation with the Mescalero Apache School.
Signature (sign in black ink)
Printed Name
Date Signed
Other Names Used
Current Address
Social Security Number
State
Zip Code
Contact Number
(
)
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.