APPLICATION for SUPPORT PERSONNEL			Return to: GRAND COUNTY SCHOOL DISTRICT 264 South 400 East Moab UT 84532
Date:			Social Security Number:
Name (Last / First / Middle):
Address (Street / City / State / Zip)
Home Phone:			Work Phone:
Date of Birth (Optional):			Place of Birth (Optional):
Dates of Military Service From: (Month / Day / Year)			To: (Month / Day / Year)
Position(s) for which you would like to apply:
List any trade or professional licenses, certificates or registrations.
Have you ever been convicted of a felony?	YES	NO	If yes, please explain:

REFERENCES - Please list three (3) persons not related to you whom you have known at least one year.
Name	Address	Telephone Number

EDUCATION High School Graduate?		YES	NO - Please circle highest grade completed 1 2 3 4 5 6 7 8 9 10 11 12
GED or Equivalent?	YES	NO
College, Business or Trade Schools Attended Name and City Location				Major or Vocational Subjects	Length of Time Attended	Date Completed	Degree

WORK HISTORY - Beginning with present or most recent, list your three most significant employers. Include military service if applicable.
Firm Name:	Dates From:	To:
Address:	Phone:
Job Title and Duties:
Reason for Leaving:
Firm Name:	Dates From:	To:
Address:	Phone:
Job Title and Duties:
Reason for Leaving:
Firm Name:	Dates From:	To:
Address:	Phone:
Job Title and Duties:
Reason for Leaving:
ADDITIONAL INFORMATION - Machines, Equipment, Tools Used, Related Activities, etc. (Attach or note on back)
CERTIFICATION OF APPLICANT I certify that all statements made in this application are true and correct, and that any misstatement of material facts may subject me to disqualification or dismissal. Also, I authorize investigation of all statements made in this application. Signature: _____________________________________________________________________________________ Date: