The Ida B. Wells Community 
Academy, Inc.

We Are An Equal Education and Employment Opportunity Institution

Employment Application for 2001 - 2004

Mail or FAX completed Application to 

Ms. Angela M. Anderson, Chief Administrative Officer
1180 Slosson Street
Phone:  330.867.1085     FAX:  330.867.1074

Please print or type your information
 

Date _________________________

Name ________________________________________________________________________________________
                              Last                                              First                                         Middle Initial

Business Telephone (      ) ___________________ Home Telephone (      ) ____________________

Social Security No. _______________________________________________ 

Present Address __________________________________________________________________________________
                                             No.                   Street                    City                    State                     Zip 

Permanent Address (if different from present address) 

________________________________________________________________________________________________
                               No.                      Street                      City                       State                       Zip

EMPLOYMENT DESIRED

Position you are applying for: ________________________________________________________________________

Are you applying for: 

          Regular full-time employment? . . . . . . . . . . . . . . . . . . .  Yes _____ No _____

          Regular part-time employment? . . . . . . . . . . . . . . . . . .  Yes _____ No _____

          Volunteer employment? . . . . . . . . . . . . . . . . . . . . . . . . Yes _____ No _____

If you are asked, what days and hours are you available to volunteer? ________________________________ 

If applying for volunteer employment, during what period of time will you be available? 

          From _______________________ To ________________________ 

Are you available to volunteer on weekends? . . . . . . . . . . . . . . .Yes _____ No _____

Would you be available to work after hours, if necessary? . . . . . Yes _____ No _____

If hired, on what date can you start? ___________________________________________________________ 

Salary (or hourly rate) desired for regular employment only: ________________________________________ 

PERSONAL INFORMATION

Have you ever applied to or worked for the Ida B. Wells Community Academy?  Yes ________ No ________

If yes, when? _____________________________________________________________________________

Do you have any relatives employed by the Ida B. Wells Community Academy? Yes____ No ____

If yes, give name(s) and relationship __________________________________________________________

Why are you applying for employment at the Ida B. Wells Community Academy?

________________________________________________________________________________________

If hired would you have a reliable means of transportation to and from work?  . .  Yes _______ No _______

Are you at least 18 years old? . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .   Yes _______ No _______ 
(Your hire is subject to verification that you are of minimum legal age and not under 18.)

If hired, can you present evidence of your U.S. citizenship or proof of your legal 
right to live and work in the United States? . . . . . . . . . . . . .. . . . . . . . . . . . . . . . Yes _______ No ______

Are you able to perform the essential functons of the job you are applying for? . .Yes _______ No ______

If no, describe the functions that cannot be performed. ____________________________________________________

_________________________________________________________________________________________________

NOTE: We comply with the ADA and Workers Compensation and we consider reasonable accommodation 
measures that may be necessary for eligible applicants/employees to perform essential functions. Your hire 
may be subject to passing a medical examination and to skill and agility tests.

Have you ever been convicted of a crime (felony or serious misdemeanor)? . . . . . . .Yes _______ No _______

If yes, state nature of the crime(s); when and where convicted and disposition of the case.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

In order to be employed by the Ida B. Wells Community Academy, you must submit a Bureau of Criminal 
Investigation form. This form and instructions for filling it out will be mailed or handed to you once your 
application has been received.

Are you currently employed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes _______ No _______

If so, where and may we contact your current employer? . . . . . . . .  . . . . . . . . . . .Yes _______ No _______

EDUCATION AND TRAINING EXPERIENCE
 

School Name and Address Years Completed Graduation Date Degree or Diploma
High School
_________________
_________________
_________________
_________________
College/University
_________________
_________________
_________________
_________________
Graduate School 
_________________
_________________
_________________
_________________
Health Care Training
_________________
_________________
_________________
_________________
Other Training
_________________
_________________
_________________
_________________

Do you speak, write or understand any foreign languages? . . . . . . . . . . . . . . . . . . Yes _______ No _______

If yes, which language(s)? ___________________________________________________________________________ 

Do you have any other experience. Training, qualifications or skills which you feel make you especially suited for employment at the Ida B. Wells Community Academy? If so, please explain: 

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Answer the following questions if you are applying for professional position. 

Are you licensed/certified for the position applied for? . . . . . . . . . . . . . . . . . . . . . .Yes _______ No _______

Name of license/certification __________________________________________________________________

Issuing state(s) ____________________________________________________________________________

License/certification number(s) _______________________________________________________________

Has your license/certification ever been revoked or suspended? . . . . . . . . . . Yes _____ No _____

If yes, state reason(s), date of revocation or suspension and date of reinstatement. 




Name(s) and telephone numbers of person(s) to be contacted in case of emergency. 

         Name ______________________ Phone No. _______________ Relationship _____________

         Name ______________________ Phone No. _______________ Relationship _____________

EMPLOYMENT HISTORY

List below all present and past employment starting with your most recent employer (last 10 years is sufficient). 
Account for all periods of unemployment. You must complete this section even if attaching a resume.

     1. Name of Employer ____________________________________________________________________

Address __________________________________________________________________________________
                           No.                  Street                        City                        State                    Zip

Type of Business __________________________________________________________________________

TeIephone No. ____________________ Your Supervisor's Name ____________________________________

Your Position and Duties ____________________________________________________________________

Date of Employment: From ____________________________ To ___________________________________

Reason for Leaving ________________________________________________________________________

     2. Name of Employer ____________________________________________________________

Address _________________________________________________________________________________
                   No.                       Street                        City                             State                 Zip

Type of Business ___________________________________________________________________

TeIephone No. ______________________ Your Supervisor's Name _________________________________

Your Position and Duties ___________________________________________________________________

Date of Employment: From ______________________________ To ________________________________

Reason for Leaving _______________________________________________________________________ 

     3. Name of Employer _____________________________________________________________

Address _______________________________________________________________________________
                   No                       Street                          City                       State                    Zip

Type of Business _______________________________________________________________________

TeIephone No. _____________________ Your Supervisor's Name _______________________________

Your Position and Duties ________________________________________________________________

Date of Employment: From _________________________ To _______________________________

Reason for Leaving _______________________________________________________________________

MILITARY SERVICE

Have you obtained any skills or abilities as a result of service in the military? . . Yes _______ No _______

If so, describe ______________________________________________________________________________

__________________________________________________________________________________________

REFERENCES

List below three persons not related to you who have knowledge of your work performance or character within the 
last three years and who can be contacted for a recommendation.

     1. Name _______________________________________________________________________________

Address __________________________________________________________________________________
                   No.                          Street                            City                        State                      Zip 

Occupation _______________________________________________________________________________

TeIephone No. (      ) _______________________ Number of Years acquainted _____________________

     2. Name ______________________________________________________________________________

Address _________________________________________________________________________________
                   No.                           Street                        City                        State                      Zip 

Occupation ________________________________________________________________________

TeIephone No. (      ) _______________________ Number of Years acquainted _____________________

     3. Name ______________________________________________________________________________

Address _________________________________________________________________________________
                    No.                           Street                        City                        State                     Zip 

Occupation ________________________________________________________________________

TeIephone No. (      ) _______________________ Number of Years acquainted _____________________

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For More Information about the Academy, Write or Call

Ms. Angela M. Anderson, Chief Administrative Officer
and Board Treasurer
or
 Mrs. Michele C. Rumrill, Principal

The Ida B. Wells Community Academy
1180 Slosson Street
Akron, Ohio   44320-2370

Phone:  330.867.1085     FAX:  330.867.1074

Send e-Mail to: IdaBWellsAcademy@Yahoo.Com


ACADEMY FORM 01 (Revised May 2, 2003)