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Applicant Information |
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Last Name: |
First Name: |
M.I. |
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Street Address: |
Apt: |
City: |
State: |
Zip: |
Phone: |
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Email: |
Date of birth: |
SSN: |
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Position Desired: |
Date Available: | |
Are you a US citizen? Yes No |
If no, are you a legal alien? Yes No |
Have you ever been convicted of a crime? Yes No |
If yes, please explain: |
Do you have any physical impairment that would interfere with your performance in the position for which you are applying?
Yes No |
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Emergency contact: |
Phone: |
Relationship: |
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References |
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Name: |
Relationship: | Company: |
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Phone: | |
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Name: |
Relationship: | Company: |
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Phone: | | |
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Name: |
Relationship: | Company: |
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Phone: | |
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Name: |
Relationship: | Company: |
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Phone: | |
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Education |
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High School: |
City and State: |
Dates Attended: |
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Graduation Date: |
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College or University: |
City and State: |
Dates Attended: |
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Graduation Date: |
Degree: |
Total Semester Hours: |
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Graduate School: |
City and State: |
Dates Attended: |
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Graduation Date: |
Degree: |
Total Semester Hours: |
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College Activities: |
Hobbys, special interests: |
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Student Teaching |
School: |
Grade/Subject: |
Dates: |
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Supervising Teacher: |
Principal: |
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Certification |
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Do you hold a National Teaching Certificate? Yes No |
If yes, expiration date: |
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Certification area(s): |
Certification Type: | Provisonal
Standard
Non-traditional |
| Do you hold any administration certificates? Yes No |
If yes, what grade levels? |
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Other education, training, certification or comments: |
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Teaching Experience |
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Dates: |
School: |
Address: |
Subject/Grade: |
Full Time? |
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Reason for Leaving: |
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Dates: |
School: |
Address: |
Subject/Grade: |
Full Time? |
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Reason for Leaving: |
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Dates: |
School: |
Address: |
Subject/Grade: |
Full Time? |
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Reason for Leaving: |
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Dates: |
School: |
Address: |
Subject/Grade: |
Full Time? |
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Reason for Leaving: |
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Dates: |
School: |
Address: |
Subject/Grade: |
Full Time? |
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Reason for Leaving: |
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Non-Teaching Experience |
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Company: |
Phone: |
Address: |
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Supervisor: |
Title: |
Starting/Ending Salary: |
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Start Date: |
End Date: |
Reason for leaving: |
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Responsibilities: |
May we contact this employer for a reference? Yes No |
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Company: |
Phone: |
Address: |
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Supervisor: |
Title: |
Starting/Ending Salary: |
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Start Date: |
End Date: |
Reason for leaving: |
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Responsibilities: |
May we contact this employer for a reference? Yes No |
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Company: |
Phone: |
Address: |
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Supervisor: |
Title: |
Starting/Ending Salary: |
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Start Date: |
End Date: |
Reason for leaving: |
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Responsibilities: |
May we contact this employer for a reference? Yes No |
| Military Service |
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Branch: |
From: |
To: |
Rank at discharge: |
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Type of discharge: |
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Agreement |
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal without notice at any time during my employment.
I agree, if employed to follow all rules and regulations of the district.
I understand by state law the board of education must require all employees to submit to health certificates from their physician along with a chest X-Ray report or tuberculin test yearly. I further understand and agree to promptly notifiy the district of any change of address during my employment. Agree Disagree |