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, Akron, Ohio  44320-2730
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) 

_________________________________________________________________________________________
                              Street                               City                            State                       Zip

EMPLOYMENT TYPE 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
 

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 ______________________ 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.

     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 _____________________

__________ I hereby certify that I have not knowingly withheld any information that might adversely affect my 
chances for employment and that the answers given by me are true and correct to the best of my knowledge. 
I further certify that I, the undersigned applicant, have personally completed this application. I understand that 
any omission or misstatement of material fact on this application or on any document used to secure 
employment shall be grounds for rejection of this application or for immediate discharge if I am employed, 
regardless of the time elapsed before discovery. I further understand that this applies specifically to a Bureau
of Criminal Investigation check which reports I have committed serious criminal offenses within a ten-year 
period. If such a report comes to the attention of the Principal, Superintendent and the Academy's Board of 
Governors after I am hired, the Board shall          deliberate on the matter and decide to retain or discharge me.

__________ I hereby authorize the Ida B. Wells Community Academy to thoroughly investigate rny references, 
work record, education and other matters related to my suitability for employment and, further, authorize the 
references I have listed to disclose to the Ida B. Wells Community Academy any and all letters, reports and 
other information related to my work records, without giving me prior notice of such disclosure. In addition, I 
hereby release the Ida B. Wells Community Academy, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related
to such investigation or disclosure.

__________ I understand that nothing contained in the application, or conveyed during any interview which may 
be granted or during my employment, if hired, is intended to create an employment contract between me and 
the Ida B. Wells Community Academy. In addition, I understand and agree that if I am employed, my 
ernployrnent is for no definite or determinable period and may be terminated at any time with or without prior 
notice and at the option of the Board of Governors of the Ida B. Wells Community Academy. I also understand 
that no promises or representations contrary to the foregoing are binding on the Ida B. Wells Community 
Academy unless made in writing and signed by me and the Ida B. Wells Community Academy's designated representative. 
 

Date ____________________ Applicant's Signature ________________________________________________

The facts set forth in my application for employment are true and complete. I understand that if employed, any 
false statement or omission of information on this application may result in my disqualification or dismissal. I 
further understand that this is not intended to be a contract of employment, nor does this application obligate 
the employer in any way if the employer decides to employ me. You are hereby authorized to make any 
investigation of my personal history and financial and credit record* through any investigative or credit 
agencies or bureaus of your choice.

I hereby fully waive any rights or claims I have or may have against all current and/or former employers, and 
their agents, employees and representatives, and damages that may directly or indirectly result from the 
use, disclosure or release of any such information by any person or party, whether such information is 
favorable or unfavorable to me. I further waive a ny claim against the Ida B. Wells Community Academy 
as a result of any information which it obtains in this investigation. A copy of this document is the same as 
an original.

In making this application for employment, I authorize you to undertake an investigative consumer report 
whereby information is obtained through personal interviews with my neighbors, friends, or others with whom 
I am acquainted. This inquiry, if made, may include information as to my character, general reputation, 
personal characteristics and mode of living. I understand I have the right to make a written request within a 
reasonable period of time to receive additional detailed information about the nature and scope of any such 
investigative report that is made.

Date _____________________ Signature of Applicant _____________________________________________

*Should a consumer credit report be processed, you are entitled to receive a copy. Please Initial your 
response below.