Fillable APPLICATION FOR CLASSIFIED POSITION

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APPLICATION FOR CLASSIFIED POSITION

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520 Butler Farm Road - Hampton, VA 23666
Phone: 757-766-1100 - Fax: 757-766-9402
Web site: http://www.nhrec.org
APPLICATION FOR CLASSIFIED POSITION
Applicant’s Last Name First Name, Middle Initial
Other Name(s)
Address – Street City State Zip
Telephone Number - Home Telephone Number – Work Telephone Number – Cellular
E-Mail Address
Check Type of Position for which you are applying:
Custodial
Grounds Maintenance
On Call Classroom Substitute
Driver
Mentor Program Specialist
Teacher Assistant
Finance
Secretary
Other:
Food Service Assistant
Substitute Driver
Have you ever been employed by New Horizons? Yes No
If so, in what capacity and please give the school year that you worked? _____________________________
I. Education
Level of
Education
Name of School or
University
State Field of Study
Type of
Degree
Year of
Graduation
Dates of
Attendance
From - To
High
School
College or
University
Other
Education
G.E.D.
New Horizons requires proof of education including High School Diploma.
Are you a U.S. Citizen? Yes No
If not, please explain why you are legally eligible to work in the U.S:___________________________________
HR-2 Revised 09/2015 1
II. Work Experience (List most recent experience first.) Please use supplementary sheets for
additional information. Please complete all sections and do not use “see resume”.
Starting with the most recent job, describe ALL paid military and applicable voluntary experience. Highlight
your knowledge, skills and abilities, which best demonstrate your qualifications for this position. You may
list significantly different jobs within the same organization as separate items. May we contact your present
supervisor?
Yes No
A. Job Title
Duties:
Employer
Address
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment used
Dates (mo/yr)
To (mo/yr)
Reason for leaving
Full-time
__
Part-time
___
Hours/week
_____
Your name if different from present
B. Job Title
Duties:
Employer
Address
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment used
Dates (mo/yr)
To (mo/yr)
Reason for leaving
Full-time
_
Part-time
____
Hours/week
_____
Your name if different from present
C. Job Title
Duties:
Employer
Address
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment used
Dates (mo/yr)
To (mo/yr)
Reason for leaving
Full-time
Part-time
Hours/week
Your name if different from present
III. GENERAL INFORMATION
A. Date available for employment (mm/dd/yyyy): ______________________________________
B. What is your salary requirement? _________________________________________________
C. Referral Source: New Horizons Posting Newspaper Advertising Employee
Friend Other:_________________
D. Are you receiving benefits from the Virginia Retirement System? (VRS) Yes No
E. Have you ever been discharged or requested to resign from a position? Yes No If yes, please
explain:__________________________________________________________________
F. Have you ever been convicted of a misdemeanor or felony other than a minor traffic violation?
Yes No If yes, please explain:________________________________________
G. Are any criminal charges or proceedings pending against you? Yes No If yes, please explain:
_______________________________________________________________________
H. Have you been convicted of any offense involving the sexual molestation, physical or sexual abuse or rape of
a child?
Yes No If yes, please explain:___________________________
HR-2 Revised 09/2015 2
IV. REFERENCES: It is the applicant's responsibility to provide New Horizons with at least three (3) work
references. One must be your current employer, if employed, and at least one (1) past employer.
Name
Title
Address
Phone Number
Please list below the names of at least two (2) personal references.
Name
Relationship
Address
Phone Number
X. OTHER INFORMATION
A. To avoid conflict of interest, list any relatives who serve on the Board of Trustees or relatives employed by New
Horizons and site relationship._________________________________________________________
B. Please provide any additional information you desire that will afford an additional understanding of your
qualifications. Your goals, objectives, philosophy, and other background factors are of special interest.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
By choosing "Accept" from the agreement box below, I authorize New Horizons Regional Education Centers to conduct a
background investigation and also authorize release of information in connection with my application for employment. This
investigation may include such information as criminal or civil convictions, driving records, if applicable, previous employers
and educational institutions, personal references, professional references, and other appropriate sources. I waive my right of
access to any such information, and without limitation hereby release to New Horizons and the reference source from any
liability in connection with its release or use. This release includes the sources cited above and specific examples as follows:
the local Sheriff, information from the Central Criminal Records Exchange of either data on all criminal convictions or
certification that no data on criminal convictions are maintained, information from the Virginia or other State Department of
Social Services Child Protective Services Unit and any Locality to which they may refer for release of information pertaining
to any findings of child abuse or neglect investigations involving me.
Furthermore, I certify that I have made true, correct and complete answers and statements on this application in the knowledge
that they may be relied upon in considering my application, and I understand that any omission, falsely answered statement
made by me on this application, or any supplement to it will be sufficient grounds for failure to employ or for my discharge
should I become employed with New Horizons. I am aware that fingerprinting is a part of the application process.
I agree with all the above terms and conditions. Accept
NEW HORIZONS REGIONAL EDUCATION CENTER IS AN EQUAL OPPORTUNITY EMPLOYER
In compliance with Executive Order 11246; Title II of the Education Amendments of 1976; Title VI of the Civil Rights Act of 1964, as
amended by the Equal Employment Opportunity Act of 1972; Title IX Regulation Implementing Education Amendments of 1972, Section
504 of the Rehabilitation Act of 1973; and all other federal, state, school rules, laws, regulations, and policies, New Horizons Regional
Education Centers shall not discriminate on the basis of sex, age, race, color, national origin, religion or disability in its education programs
and activities which it operates nor provisions of employment and services. Any complaints of alleged discrimination under Title IX (sex)
and Section 504 (disability) should be referred to: Human Resources Department, 520 Butler Farm Road, Hampton, VA 23666, (757) 766-
1100, ext. 3377.
HR-2 Revised 09/2015 3
WORK EXPERIENCE SUPPLEMENT
D. Job Title
Duties:
Employer
Address
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment used
Dates (mo/yr)
To (mo/yr)
Reason for leaving
Full-time
__
Part-time
___
Hours/week
_____
Your name if different from present
E. Job Title
Duties:
Employer
Address
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment used
Dates (mo/yr)
To (mo/yr)
Reason for leaving
Full-time
__
Part-time
____
Hours/week
_____
Your name if different from present
F. Job Title
Duties:
Employer
Address
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment used
Dates (mo/yr)
To (mo/yr)
Reason for leaving
Full-time
Part-time
Hours/week
Your name if different from present
HR-2 Revised 09/2015 4
NEW HORIZONS REGIONAL EDUCATION CENTERS
520 BUTLER FARM ROAD
HAMPTON, VIRGINIA 23666
(757) 766-1100 X 3377 FAX (757) 766-9402
Attn: Human Resources
Verification of Previous Work Experience
*Please give to your previous employer before you turn in application.*
PART I- To be completed by EMPLOYEE and forwarded to previous employer.
NAME
(Print)_________________________________________________________________________
(Last) (First) (Middle) (Maiden)
Social Security Number ________/________/___________
I am being considered for a position with New Horizons Regional Education Centers. In order to substantiate my
previous experience for salary purposes, will you kindly verify the information in Part II below? Your promptness in
returning this form directly to the address listed or fax will be appreciated. My salary placement is pending receipt of
this information.
Exact Dates of Service: From (mo./yr.)_____________________to (mo./yr.) _________________
__________________________________ ___________________________
Signature Date
PART II- To be completed by previous employer.
***NAME OF EMPLOYER____________________________________________________
FROM: MONTH______ YEAR______ TO MONTH______ YEAR______ TOTAL MONTHS ___________
FULL TIME_______* PART TIME________
*FOR PART-TIME EMPLOYMENT, PLEASE INDICATE PERCENTAGE OF TIME. __________
SALARY AMOUNT:______________(ANNUAL) _________________(HOURLY)
NUMBER OF DAYS CONTRACTED_______________
POSITION HELD____________________________________________________
If there was an extended leave of absence granted during employment, please indicate nature of
leave and exact dates.____________________________________________________________
Is the employee listed above eligible for re-hire ________ Yes_________ No
If the employee is not eligible for re-hire please explain:__________________________________
Signature: ________________________________ Date:________________________
Position: ________________________________
HR-2 Revised 09/2015 5
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APPLICATION FOR CLASSIFIED POSITION

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Completed 6 July 2021

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