Logistics Staffing Substitute Teacher Application Step 1 of 9 11% Full Name* First Middle Initial Last Date* MM slash DD slash YYYY Address* Street Address Apartment/Unit # City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Date Available* MM slash DD slash YYYY Social Security No.* Driver's License No. Are you a citizen of the United States?* Yes No If no, are you authorized to work in the U.S.?* Yes No Have you ever worked for this company?* Yes No If yes, when? EducationHigh School* Address From To Did you graduate?* Yes No Diploma College Address From To Did you graduate? Yes No Degree Other Address From To Did you graduate? Yes No Degree Previous EmploymentCompany* Phone*Address* Supervisor* Job Title* Starting Salary* Ending Salary* Responsibilities* Starting Date* Ending Date* Reason for Leaving* Company PhoneAddress Supervisor Job Title Starting Salary Ending Salary Responsibilities Starting Date Ending Date Reason for Leaving Company PhoneAddress Supervisor Job Title Starting Salary Ending Salary Responsibilities Starting Date Ending Date Reason for Leaving Staffing Work HistoryPlease list all staffing companies where you have been employed:1. 2. 3. 4. 5. 6. School Placement / Volunteer HistoryPlease list all schools where you have been placed or volunteered:1. 2. 3. 4. 5. 6. Military ServiceBranch From To Rank at Discharge Type of Discharge If other than honorable, explain: Disclaimer and SignatureConsent* I certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.SignatureDate MM slash DD slash YYYY Federal and State Criminal History Record (CHRI)Each applicant must submit with his/her employment application a copy of a Federal Criminal Record from the Federal Bureau of Investigation (FBI) and State Criminal Record from the Michigan State Police (MSP). Prospective employees must submit ORIGINAL report, which may not be more than one (1) year old.You must give complete answers to all questions. If you answer "Yes" to any question, you must list all offenses, and for each conviction provide date of conviction and disposition, regardless of the date or location of occurrence. Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merits. Your answers will be verified with appropriate police records. Criminal Offense includes felonies, misdemeanors, summary offenses and convictions resulting from a plea of "nolo contendere" (no contest). Conviction is an adjudication of guilt and includes determinations before a court, a district justice or a magistrate, which results in a fine, sentence or probation.Were you ever convicted of a criminal offense?* Yes No Are you currently under charges for a criminal offense?* Yes No Have you ever forfeited bond or collateral in connection with a criminal offense?* Yes No Within the last ten years, have you been fired from any job for any reason?* Yes No Within the last ten years, have you quit a job after being notified that you would be fired?* Yes No Have you ever been professionally disciplined in any state?* Yes No Professional disciplined means the annulment, revocation or suspension of your teaching certification or having received a letter of reprimand from an agency, board or commission of state government, such as the Pennsylvania Professional Standards and Practices Commission.Are you subject to any visa or immigration status, which would prevent lawful employment?* Yes No File UploadMax. file size: 32 MB.If you answered "Yes” to any of the above questions, please provide a detailed explanation on a separate sheet of paper, including dates, and attach it to this application. Please print and sign your name on the sheet and include your social security number.Consent* I certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.SignatureDate MM slash DD slash YYYY Certification and Release Authorization I certify that all of the statements made by me are true, complete and correct to the best of my knowledge and belief and are made in good faith. I further certify that I am the sole author of the essay. I understand that any misrepresentation of information shall be sufficient cause for: (1) rejecting my candidacy, (2) withdrawing of any offer of employment, or (3) terminating my employment. I hereby authorize any and all of my previous employers and/or supervisors to release any and all of my personnel records, and to respond fully and completely too all questions that officials of Industry Specific Staffing may ask regarding my prior work history and performance. I will hold such previous employers and/or supervisors harmless of any and all claims that I might otherwise have against them with regard to statements made to this school district. I further authorize these officials to investigate my background, now or in the future, to verify the information provided and release from liability all persons and/or entities supplying information regarding my background. I also hereby authorize Industry Specific Staffing (ISS) to release any and all personal identification, including social security number, transcripts and certification information to a school district, local act school district, public school academy, intermediate school district, or nonpublic school. I will hold ISS harmless of any and all claims that I might otherwise have against them with regard to sharing the above stated information. I further authorize a school district, local act school district, public school academy, intermediate school district, or nonpublic school to investigate my background, now or in the future, to verify the information provided and release from liability ISS and /or entities supplying information regarding my above stated information. However, I do not authorize the production of medical records or other information, which would tend to actually identify a disability, nor do I authorize inquiries which would include information related to any medical condition or medical history. Further, I do not waive any rights which I may have under state or federal law related to my right to challenge the disclosure of unlawful or inaccurate information, whether by the school district or by entities or persons providing such information to the school district, including any and all claims concerning allegations of employment discrimination because of race, color, sex, religion, national origin, ancestry, age or disability.Signature Unprofessional Conduct DisclosureI (PRINT NAME) authorize my former employer (Employer Name) to complete the attached form and forward it back to Industry Specific Staffing (ISS) within the required 20 day period.Full Name* Former Employer's Name* Employer Contact Name* Employer Phone and Email* THE: REVISED SCHOOL CODE (EXCERPT) Act. 451 of 1976 380.1230b Applicant for employment; information regarding unprofessional conduct to be provided by previous employer; signed statement authorizing disclosure; request; immunity from civil liability; prohibition; use. of Information; violation of subsection (5) as misdemeanor; effect of contract or agreement; other information; definitions Sec. 1230b, (1) Before hiring an applicant for employment, a school district, local act school district, public school academy, Intermediate school district, or nonpublic school shall request the applicant for employment to sign a statement that does both of the following: (a) Authorizes the applicant's current or former employer or employers to disclose to the school district, local act school district, public school academy, intermediate school district, or nonpublic school any unprofessional conduct by the applicant and to make available to the school district, local act school district, public school academy, Intermediate school district, or nonpublic school copies of all documents in the employee's personnel record maintained by the current or former employer relating to that unprofessional conduct. (b) Releases the current or former employer, and employees acting on behalf of the current or former employer, from any liability for providing Information described in subdivision (a), as provided in subsection (3), and waives any written notice required under section 6 of the Bullard-Plawecki employee right to know act, Act No. 397 of the Public Acts of 1978, being section 423.506 of the Michigan Compiled Laws. (2) Before hiring an applicant for employment, a school district, local act school district, public school academy, Intermediate school district, or nonpublic school shall request at least the applicant’s current employer or, if the applicant is not currently employed, the applicant's immediately previous employer to provide the Information described in subsection (1)(a), if any. The request shall Include a copy of the statement signed by the applicant t under subsection (1). (4) The board or governing body of a school district, local act school district, public school academy, Intermediate school district, or nonpublic school shall not hire an applicant who does not sign the statement described in subsection (1).SignatureDate MM slash DD slash YYYY Register of Education for Personnel (REP)Employee Information For Michigan Department of Education Districts are required to report all school personnel to the Michigan Department of Education through the Registry of Educational Personnel. This requirement is a result of the recent School Safety Legislation (2005 PA 129-131,138) that went into effect on January 1, 2006. The following Information is requested from you for the full and accurate reporting of your record. We have your permission to release this Information to the districts upon their request.SignatureToday's Date MM slash DD slash YYYY First Name* Middle Name* Last Name* Date of Birth* MM slash DD slash YYYY Social Security Number* Gender*FemaleMaleRacial/ Ethnic Category American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander Multiracial White / Caucasian Highest Education Level None High School Diploma or GED Associates Degree Bachelor’s Degree Master’s Degree Specialist’s Degree Doctoral Degree Juris Doctorate Medical Degree Other License, Credential or Professional Degree Obtained Paraprofessional Quality Standard on State Academic Assessment Institution Obtained Degrees From1. 2. 3. 4. 5. 6. Contractor Disclosure and Release Policy While working as a contractor with Industry Specific Staffing (ISS), I understand that I may not seek full or part-time employment with any customer, facility or domicile site that ISS dispatches me to directly or indirectly for a period of six (6) months after my separation from ISS. It is also understood that a customer may agree to hire an ISS Contractor after that contractor has met the requirements. However, the customer nor ISS obligates themselves to this option and shall not be held to any such agreement at any time a contractor is assigned. Client is not permitted to solicit or employ an INDUSTRY SPECIFIC STAFFINGS’ staff directly or indirectly other than through INDUSTRY SPECIFIC STAFFING prior to the hourly staff member completing 1568 work hours, or substitute teaching staff working a minimum of 180 days within one school year. Please sign below to confirm that you have read and agree to the above ISS’s Contractor Disclosure and Release Policy.Signature Conviction Disclosure FormFull Name* Date of Birth* School District Name Pursuant to Public Act 138 of 2005, I attest that (select one): 1. I have not been convicted of or pled guilty or nolo contendre (no contest) or am I the subject of a finding of guilt by a judge or jury of any crime. 2. This is my initial disclosure, I have been convicted of; or pled guilty or nolo contendre (no contest) or am the subject of a finding of guilt by a judge or jury for the following crimes (attach a separate sheet of paper to explain the criminal offense, date, court, city/state, and circumstance, surrounding the conviction): 3. This serves as disclosure of subsequent convictions for which I have been convicted of or pled guilty or nolo contendre (no contest) or am the subject of a finding of guilt by a judge or jury for the following crimes (attach a separate sheet of paper to explain the criminal offense, date, court, city/state, and circumstance, surrounding the conviction), and I understand that failure to disclose any subsequent convictions is considered to be a crime. Felony Misdemeanor Conviction Felony Misdemeanor ConvictionFile UploadAccepted file types: jpg, png, doc, docx, pdf, Max. file size: 32 MB.A separate sheet of paper to explain the criminal offense, date, court, city/state, and circumstance, surrounding the conviction.In signing this form, I understand and agree that: 4. If I have been convicted of a listed offense, my employment shall be terminated. I also understand that if I have been convicted of a felony. other than a listed offense, the superintendent, or chief school official and the board or governing body must each approve, in writing, to my employment. 5. Until the criminal history report is received and reviewed by the employing school/district, I am regarded as a conditional employee and if the criminal history report is not the same as my representation(s) above, my employment contract may be voided at the discretion of the employer. 6. Listed Offenses: Accosting, enticing, or soliciting a child for immoral purposes. Involvement in child sexually abusive activity or material. A third or subsequent violation of any combination of engaging in obscene or indecent conduct in public, indecent exposure, or a local ordinance substantially corresponding to either offense. First, second, third, or forth degree Criminal Sexual Conduct (CSC). Assault with intent to commit CSC. If the victim is less than 18 years of age, the crime of gross indecency (except for a juvenile disposition or adjudication), kidnapping. sodomy, or soliciting another for prostitution. Leading, enticing, or carrying away a child under 14 years of age. Pandering. Any other violation of a state law or local ordinance constituting a sexual offense against an individual less than 18 years of age. An offense committed by a sexually delinquent person. An attempt or conspiracy to commit one of the offenses listed above. Consent* I certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.Signature MICHIGAN WAIVER AGREEMENT AND STATEMENT FOR SCHOOLS An Individual Applicant’s Request for a Fingerprint Based Criminal History Record Information (CHRI) Background Check Result for a Qualified Entity in Accordance with the Michigan School Volunteer & Employee Criminal History Program Pursuant to the National Child Protection Act (NCPA) of 1993, as amended by the Volunteers for Children Act (VCA), this form should be completed and signed by every current or prospective employee, volunteer, and contractor/vendor, for whom criminal history records are requested by a qualified entity (i.e. school or management company) under these laws. I hereby authorize (name of Qualified Entity) , to receive the results of my state and federal fingerprint-based CHRI background check result for the purpose of evaluating and determining my fitness to have responsibility for the safety and well-being of children or individuals with disabilities. Prior to submitting my fingerprints to the Michigan State Police to conduct a CHRI background check, I will complete, sign, and return this form and a Livescan Fingerprint Background Check Request form (RI-030). I understand the Qualified Entity will retain all required documentation for a period of time no less than prescribed by state or federal laws. By signing this Michigan Waiver Agreement and Statement, it is my intent to authorize the dissemination of any state and national CHRI that may pertain to me to the Qualified Entity with which I am, or am seeking to be, employed or to serve as a volunteer, pursuant to the NCPA VCA. I understand that until the criminal history background check is completed, the Qualified Entity may choose to deny me unsupervised access to children or individuals with disabilities. I further understand that upon request the Qualified Entity will provide me a copy of the CHRI background results, if any, and that I am entitled to challenge the accuracy and completeness of any information contained in such results. I may obtain a prompt determination as to the validity of my challenge before the Qualified Entity makes a final decision about my status; as an employee, volunteer, contractor, or subcontractor.Full Name* Date of Birth* MM slash DD slash YYYY What is your current or prospective status (check one)?* Employee Volunteer Contractor/Vendor Have you ever been convicted of a crime?* Yes No If yes, please provide a description of the crime and the particulars of the conviction.I understand that I may be asked to assist with obtaining any and all official disposition documentation regarding my conviction.If you are an employee, prospective employee, or a volunteer of a public school academy, do you authorize release of your CHRI results to another qualified entity (i.e. school or management company) for a like purpose? Yes No If yes, indicate the name of the other qualified entity below. Signature