BETHEL HILL CHARTER SCHOOL

401 Bethel Hill School Road                              APPLICATION FOR EMPLOYMENT

Roxboro, NC  27574                                                 NON-CERTIFIED

Name:  _____________________________________________________  Date:  _________________

            (Last)                                       (First)                                                     (Middle)

Present Address:  ____________________________________________ Phone: (      ) ____________

                                    (Street)                                              (city, state, zip)                    

Permanent Address:  _________________________________________________________________
                                    (Street)                                               (city, state, zip)

E-mail address  ________________________________   Earliest possible employment date ________

Social Security Number:  ________________________   NC Driver  ___________________________

Position(s) you wish to apply for  (circle)                                       Part Time                   Full Time

Assistant Teacher                        Cafeteria                      Maintence                   Office/Clerical

Custodial                                  Daycare(extended care)                            Other _________________

General Information

How did you hear about Bethel Hill Charter School?(circle)  

Advertisement        Friend        Job Fair        Internet        Local Paper        Local Radio/TV       Other

If presently employed, why do you wish to change jobs?  ____________________________________________________________________________________________________________________________________________________________________

Have you ever been asked to resign from a position of employment?                                Yes            No

Have you ever been convicted of  a violation of law other than traffic violations?    Yes            No

Are any criminal charges or proceedings pending against?                                     Yes            No

May we contact your present/former employer?                                                         Yes            No

            Name:  _______________________________  Phone number:  _________________________

Reference:  Please supply three references including name, phone number and address.

1)_________________________________________________________________________________

2)_________________________________________________________________________________

3)_________________________________________________________________________________

Narrative                   _______________    (For Teacher, Assistant & Office/Clerical Applicants)

Please attach a narrative in your own handwriting stating you reasons for wanting to teach at Bethel Hill Charter School.

NON-DISCRIMINATION POLICY

It is the policy of Bethel Hill Charter School not to discriminate on the basis of sex, race, religion, color, creed, national origin, handicap, or age in its education program, actives, or employment.

Applicant's Signature:  ___________________________________________ Date:  ____________

CERTIFCATE OF RELEASE

I, the undersigned applicant/employee, hereby expressly authorize Bethel Hill Charter School officials to make any investigation of my personal or employment history, expressly including, but not limited to, federal and/or state criminal, law enforcement or traffic records.  I further authorize any former employer, person, firm, corporation, credit agency, administrative body or governmental agency to give to the Bethel Hill Charter School officials any information they may have regarding me.  In consideration of the review of my employment application by Bethel Hill Charter, I hereby release Bethel Hill Charter and any and all providers of information to whom this release is sent from any liability as a result of furnishing or receiving this information.

            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 or falsely answered statements 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 Bethel Hill Charter School.

Full Name Printed:              ______________________________________________________________

Maiden Name:              ______________________________________________________________

If you have been married more than once, please list all other married names below:

________________________________________________________________________________

Date of Birth:  ____________________________________________________________________

Signature:               ____________________________________________________________________

Signature of Principal:  _____________________________________________________________

E-mail:  bhcsk6@esinc.net                                                               Web Site:  http://esinc.net/bhcs

Telephone:  336-599-2823                                                 Fax:  336-599-9299