270 Mayfield Road Clarion, pa 16214

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270 Mayfield Road

Clarion, PA 16214

814-226-7103 or 800-672-7123 (PA only)

Fax: 814-226-4850


Social Security Number:
Permanent Address: Current Address:
___________________________________ ______________________________________

P O Box or Street P O Box or Street

___________________________________ ______________________________________

City/State Zip City/State Zip

Telephone ( ) ____________________ Telephone ( ) ________________________
Position(s) Desired


Check status desired  Full-time  Substitute  Part-time
Referral Source  Advertisement  Employee  Relative

 Walk In  Other

It is the policy of the Riverview Intermediate Unit not to discriminate on the basis of sex, disability, race, age, color, or national origin in its educational and vocational programs, activities or employment as required by Title IX, Section 504 and Title VI. For information relevant to this policy contact the Administrative Assistant for Personnel of Riverview Intermediate Unit 6, 270 Mayfield Road, Clarion PA 16214.

Have you worked for Intermediate Unit 6 before?  No  Yes When ____________

Have you applied before?  Yes  No


Name & Location

Credits Received

Degree/Diploma or Certificate


High School

College or University

Graduate School



Type Code

Years Valid

Date Issued

Area of Certification


If you do not presently have an Instructional II certificate, how many years of the above teaching experience are you claiming toward your Instructional II certificate? __________ years

Have you acquired tenure in Pennsylvania? _________

If yes, in which school district? _____________________________

Attach a photocopy of certificate(s). Certification is the responsibility of the applicant/employee. Applicants seeking employment by the Riverview Intermediate Unit must possess a valid Pennsylvania Certificate for the position for which they are applying. A copy of such certificate must be filed with the personnel office. It is recommended that a copy of the certificate be filed with this application. Upon employment the certification must be kept valid as may be required by Pennsylvania Laws and/or regulations. A person whose application and/or records or certificate has been falsified and/or who does not possess a valid certificate will be subject to immediate dismissal.

PROFESSIONAL EXPERIENCE (Please include student teaching)


Name & Address of Employer



Section 1418 of the Pennsylvania School Code requires a pre-employment physical examination and evidence of a tuberculosis test within a two-year period. Before employment, evidence of such examination and test must be filed in the personnel office. Forms may be secured in the personnel office. No one may begin work before completing these examinations.
Section111 of the Pennsylvania School Code requires prospective employees to submit with the employment application a report of criminal history record from the Pennsylvania State Police. Section 111 prohibits this employer from employing any person whose criminal history indicates that the applicant has been convicted within five years immediately preceding the date of the report of one or more specific offenses under the Crimes Code, 19 CSA 101 et seq. Application submitted without the required criminal history records shall not be considered. Forms may be secured in the personnel office or from the Pennsylvania State Police.


NAME _________________________________________ JOB TITLE___________________

ADDRESS ______________________________________ FROM _______ TO ________

NAME _________________________________________ JOB TITLE___________________

ADDRESS ______________________________________ FROM _______ TO ________

NAME _________________________________________ JOB TITLE___________________

ADDRESS ______________________________________ FROM _______ TO ________

NAME _________________________________________ JOB TITLE___________________

ADDRESS ______________________________________ FROM _______ TO ________

Have you been convicted of a felony in the last seven (7) years: (Such conviction may be relevant if job related, but does not bar you from employment.)  No  Yes, please explain _______


REFERENCES (List at least three who are not related to you)
NAME _________________________________________ POSITION___________________

ADDRESS ______________________________________ TELEPHONE _____________

NAME _________________________________________ POSITION___________________

ADDRESS ______________________________________ TELEPHONE _____________

NAME _________________________________________ POSITION___________________

ADDRESS ______________________________________ TELEPHONE _____________

NAME _________________________________________ POSITION___________________

ADDRESS ______________________________________ TELEPHONE _____________

The facts set forth in my application for employment are true and complete and I understand that, once submitted to the Personnel Office, this application becomes the property of IU #6. All applications will be held one year from the date of the application.
I understand that, if employed, any misrepresentation of information on this application or any supplement thereto shall be sufficient cause for dismissal of my employment.
Riverview Intermediate Unit has instituted a Policy for Drug and Substance Abuse which prohibits the unlawful manufacture, distribution, dispensing, possession, and use of a controlled substance in the IU #6 assigned workplace, and requires any employee to notify the personnel office of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) days after such conviction.
I further authorize the Intermediate Unit to investigate my background now or in the future, to verify the information provided, and release from liability all persons and/or corporations supplying information concerning my background. Information submitted on or as part of this statement shall be accorded confidentiality as required by applicable regulations of the Pennsylvania Department of Education. This statement is made subject to the penalties of 18 PA C.S. s4904 relating to unsworn falsification to authorities.
Date ____________________ Signature _________________________________________

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