211 S 12th Street, Petersburg, IN 47567

Phone: 812-354-8731 www.pcsc.k12.in.us Fax: 812-354-8733

The Pike County School Corporation does not discriminate in hiring or employment on the basis of race, color, sex, age, handicap, religion, or national origin. No question on this form is intended to secure information to be used for such discrimination. This application will be given every consideration, but its receipt does not imply the applicant will be interviewed or employed.

THIS APPLICATION MAY BE DISCARDED AT THE END OF ONE YEAR. TO KEEP THIS APPLICATION INCLUDED IN THE ACTIVE FILES, INDIVIDUALS SHOULD WRITE OR EMAIL THE CORPORATION, INFORMING THEM OF THAT INTENT.

Please fill out all blanks with complete, detailed information.

List the Position(s) for which you would like to be considered:

Please attach a copy of College / University Transcripts. There is a spot at the bottom of the application to attach them.

List Additional Skills and/or Qualifications.

I attest that the information included in this application is true to the best of my knowledge. My signature below constitutes my authorization, waiver, and release for the Pike County School Corporation to check, and for all prior employers, supervisors, educational institutions, and state and federal agencies, and their present and former employees and agents, to divulge information relating to my qualifications for employment. Such information includes, but is not limited to, criminal history, information maintained by any teacher licensing agency, job performance evaluations, personnel file information, anecdotal records in the possession of supervisors, and any settlement agreement, by whatever name called, which resolved issues regarding my employment and any internal transfer or departure there from regardless of whether or not said agreement called for confidentiality.

My signature below also constitutes my express, voluntary waiver and release of any and all legal claims or causes of action against any and all state or federal agencies and present and former employers and their present and former employees and agents who sought or provided the above-indicated information, including the Pike County School Corporation to which I make this application for employment. Said claims or causes of action include, but are not limited to defamation, infliction of emotional distress, invasion of privacy, interference with contractual relations, and breach of contract. Further, said signature is my express, voluntary promise to hold said entities and individuals harmless from any and all liability, costs, or damages, including fees, resulting from said legal claims or causes of action. I have read and understood this Authorization, Waiver, and Release and expressly and voluntarily agree to its terms.

You can submit your application using either option below: 1) Print, Sign in the "signed by" box, and Return your application to the Central Office: Pike County School Corporation, Att: Dana Deffendoll, 211 S 12th Street, Petersburg, IN 47567 2) Electronically Sign and Submit your Application by Email. With this option, you do not need to print this document. Your application will immediately be sent to the PCSC Central Office.