The completion of this questionnaire is completely voluntary. The purpose of this questionnaire is to assist the District in evaluating its recruitment program to determine if it is attracting persons of all ethnic backgrounds and handicapped individuals, as defined by the Vocational Rehabilitation Act of 1973. The District’s affirmative action policy provides for increased employment opportunities for handicapped individuals and ethnic minorities as well as women and men in areas where there is a lack of representation or utilization. It will be helpful to us if you will provide the following information and return it with your application. Results of this survey will also assist us in developing the District’s goals for increased employment opportunities for qualified handicapped individuals, monitor the results of our recruitment efforts, and make accommodations to handicapped applicants in the interview situation if appropriate.

GENDER:
MALE FEMALE

AGE:
Under 40 Over 40

HANDICAPPED:
Specify nature:

ETHNIC BACKGROUND:
American Indian (including Alaskan Natives)
Black
White (non-Hispanic origin)
Asian (check one category): Chinese Japanese Korean Vietnamese
Pacific Islander (check one category): Hawaiian Guamanian Samoan
Hispanic (Including persons of Mexican, Puerto Rican, Cuban, Central or South American, or Spanish origin or culture)
Filipino
Other:

Please indicate how you originally learned about this employment opportunity:

Posted at a college/university:
JOB/RECRUITMENT FAIR:
city
state
date
I called the AVUHSD Personnel Office
AVUHSD walk-in
Newspaper:
Posted at a AVUHSD facility or school site
AVUHSD’s Internet Site
Other Internet site:
Employment Department
Other

POSITION APPLIED FOR:
DATE:

please scroll down to continue application

CERTIFICATED (TEACHER) EMPLOYMENT APPLICATION
Please list the subject area(s) you are applying for:

Last Name:
First Name and Middle Name
Other Name

Current Address:
Street City State
Zip Phone

Permanent Address:

Street City State
Zip Phone

Social Security Number:
Disclosure of your social security number on this form is voluntary. If employment is offered to you, it will be necessary that your provide your social security card for drug testing identification purposes, income tax reporting, social security withholding, and payroll record keeping. If you answer "YES" to any of the following, you must attach a signed and dated sheet of explanation, include all circumstances, including date, location, etc.

NO YES Have you ever been convicted of a crime?
NO YES Has your credential ever been suspended or revoked?
NO YES Have you ever been dismissed or asked to resign from any job?
NO YES Have you ever worked for the Antelope Valley Union High School District in any capacity?

CALIFORNIA CREDENTIALS HELD
Type, Subject Area, Date of Expiration:
Type, Subject Area, Date of Expiration:
Type, Subject Area, Date of Expiration:

OUT OF STATE CREDENTIALS HELD
Type, Subject Area, Date of Expiration:
Type, Subject Area, Date of Expiration:
Type, Subject Area, Date of Expiration:

Name of California Teaching Credential Applied for:
Date of Application:
Are you currently enrolled in a CredentialProgram? NO YES
If yes, list school name and scheduled completion date:
Have you taken the Praxis?
YES NO
Have you taken and passed the CBEST? YES NO
If no, have you ever had a CBEST Waiver? YES NO

Are you now, or have you ever been, a member of the California State Teachers Retirement System?
NO YES
Do you speak any languages other than English?
NO YES (please list)

Is there any reason you would be unable to safely perform any of the duties or positions for which you have applied as set forth in the job description for this position with or without reasonable accommodation? NO YES,explain:

COLLEGE/ UNIVERSITY EDUCATION
INSTITUTION: FROM TO:
GRADUATED? DATE: MAJORMINORDEGREE:
STREET, CITY, STATE, ZIP:

INSTITUTION: FROM TO:
GRADUATED? DATE: MAJORMINORDEGREE:
STREET, CITY, STATE, ZIP:

INSTITUTION: FROM TO:
GRADUATED? DATE: MAJORMINORDEGREE:
STREET, CITY, STATE, ZIP:

Semester units of Graduate Work beyond BS or BA? Beyond MA or MS? (1 Quarter Unit=2/3 Semester Unit)
Name of placement office where placement files are located and Name filed under:
It is the responsibility of the applicant to forward placement papers.

TEACHING EXPERIENCE
GRADES/SUBJECTS:FROM : TO:
SCHOOL/DISTRICT NAME: PHONE:
STREET, CTY, STATE, ZIP:
REASON FOR LEAVING:

GRADES/SUBJECTS:FROM : TO:
SCHOOL/DISTRICT NAME: PHONE:
STREET, CTY, STATE, ZIP:
REASON FOR LEAVING:

GRADES/SUBJECTS:FROM : TO:
SCHOOL/DISTRICT NAME: PHONE:
STREET, CTY, STATE, ZIP:
REASON FOR LEAVING:

GRADES/SUBJECTS:FROM : TO:
SCHOOL/DISTRICT NAME: PHONE:
STREET, CTY, STATE, ZIP:
REASON FOR LEAVING: REASON FOR LEAVING:

NON-TEACHING EXPERIENCE
POSITION/DUTIES: FROM : TO:
COMPANY/NAME OF EMPLOYER: PHONE:
STREET, CTY, STATE, ZIP:
REASON FOR LEAVING:

POSITION/DUTIES: FROM : TO:
COMPANY/NAME OF EMPLOYER: PHONE:
STREET, CTY, STATE, ZIP:
REASON FOR LEAVING:

POSITION/DUTIES: FROM : TO:
COMPANY/NAME OF EMPLOYER: PHONE:
STREET, CTY, STATE, ZIP:
REASON FOR LEAVING:

PROFESSIONAL REFERENCES
NAME: OFFICIAL POSITION:
SCHOOL DISTRICT NAME: PHONE
STREET, CTY, STATE, ZIP:

NAME: OFFICIAL POSITION:
SCHOOL DISTRICT NAME: PHONE
STREET, CTY, STATE, ZIP:

NAME: OFFICIAL POSITION:
SCHOOL DISTRICT NAME: PHONE
STREET, CTY, STATE, ZIP:

Please submit any additional comments if you believe they will be valuable in helping AVUHSD determine your qualifications.

I HEREBY CERTIFY that all statements made herein or contained in any materials submitted by me are true and
correct to the best of my knowledge and I authorize the full investigation of all information contained therein. I understand that falsification or omission of any matters or information on this application and attached material,
or failure to pass fingerprint clearance or any other clearance for the position , or failure to obtain and maintain
any required certification as needed for this position will be sufficient cause for termination. I agree that if
employed, I will abide by all policies and procedures established by the Administration.
Print-out this document now. YOU MUST PROVIDE AN ORIGINAL SIGNATURE.

Signature: Date: .

ANTELOPE VALLEY UNION HIGH SCHOOL DISTRICT
44811 SIERRA HIGHWAY LANCASTER, CA 93534(661) 948-7655

Authorization for Drug/Substance Use Screening

Offers of employment of the Antelope Valley Union High School District are contingent upon successful completion of a required pre-placement Drug/Substance Use test and any other pre-placement physical examination required of the position. If offered employment, it is the employee’s responsibility to provide verification of freedom from tuberculosis via a Mantoux TB Test/chest x-ray every four years.

APPLICANT READ AND SIGN:

I, , consent to submit to a Drug/Substance Use
PRINT NAME

Screening and/or any other physical exam required for initial and continued employment with the Antelope Valley Union High School District and authorize the facility conducting the screening and/or exam to release said results to the Antelope Valley Union High School District. I hereby certify that I have no previous medical history or disability which would prevent me from performing the physical requirements for the position of

.
PRINT JOB TITLE

I understand that any false statement or material omission by me in connection with my physical disabilities or medical history will disqualify me from employment or be cause for dismissal.

SIGNATURE: DATE:

If you need assistance with this document please contact the Antelope Valley Union High School District Personnel Services Office via email at jobs@avhsd.org or please call (661) 948-7655 ext 0 to request a hard copy application to be mailed to you.

Be sure you have filled out and signed all applicable areas of this application. Be sure you submit all required materials with your application. Incomplete application packets will not be considered.

Thank you for your interest in the Antelope Valley Union High School District.

Mailing Address:
AVUHSD
PERSONNEL DEPT.
44811 Sierra Highway
Lancaster, CA 93534

Need information about a non-teaching position? Call our 24-hour JOB HOTLINE for non-teaching positions: (661) 948-7655 ext 849, or click here.