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Date___________________________
PERSONAL:
Name___________________________________
SS#______________________
Present
Address_____________________________________________________
Permanent
Address___________________________________________________
Home
Phone#____________________ Work Phone#________________________
Have
you ever been convicted of a felony?________If so, wha___________________
EMPLOYMENT
DESIRED: ____________________________________________
List
any special skills you possess:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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EDUCATION: |
Name
of School |
#
Years Attended |
Graduated
Yes \ No |
Major
Field |
|
High
School |
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College
or University |
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College
or University |
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AVAILABILITY
Date
you can start_________________ Are you employed
now?_________________
If
so, may we inquire of your present
employer?_______________________________
May
we contact other references prior to an
interview?_________________________
FORMER
EMPLOYERS: Please list below your last four employers
(most recent one first).
|
Month/Year |
Name/Address
of Employer |
Home
Phone |
Work
Phone |
Position
Held |
Reason
for Leaving |
|
From
To |
|
|
|
|
|
|
From
To |
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From
To |
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From
To |
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REFERENCES:
Give below the names of three persons not related to you whom you
have known at least one year (preferably
in the teaching profession).
|
Name |
Address |
Phone
# |
Occupation |
Years
Acquainted |
|
|
|
|
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CERTIFICATION:
I hereby certify that the information given by me in this
application is true, correct and complete; and, I hereby authorize
personnel in the district to examine my records and contact any of
my schools, former employers, education, certification, experience
and fitness as a teacher, and I agree to hold any and all of such
references harmless and free of any liability for releasing any
truthful information about me.
I understand that failure to provide employment or employer history
requested in this application which is material to my qualifications
for employment as a teacher or the provision of statements which I
do not believe to be true may be a Class A misdemeanor. For purposes
of this application, I shall be deemed to have made a false
statement if I make a statement which I do not believe to be true or
if I knowingly omit or fail to include any employment or employer
history required to be furnished on this application.
I understand that if I am employed, any false or misleading
statement made or implied on this application, any omission herefrom,
or any inconsistency between the information I have provided herein
and information obtained from any criminal history records check,
Statewide Sex Offender Database check, Statewide Child Murderer and
Violent Offender Against Youth Database check, or background
investigation is sufficient cause for dismissal.
_______________________________________
________________________
Signature
Date
APPLICATIONS
REMAIN ACTIVE FOR ONE YEAR-REAPPLICATION IS NECESSARY
AFTER THAT
TIME
Do
not write below this line
Date
of Interview____________ Time________ Interviewed
by:_________________
Remarks___________________________________________________________
__________________________________________________________________
__________________________________________________________________
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