Certified Staff Application

Gregory School District 26-4 Certified Staff Application

Phone: (605)835-9672 Fax: (605)835-8146 www.gregory.k12.sd.us 505 Logan Ave Gregory, SD 57533
Applicants are requested to fill this form out in its entirety. Please mail your application, a complete resume, and your current teacher credentials to the address above or e-mail them to sara.anderson@k12.sd.us. Have your placement office forward your credential file to the attention of Sara Anderson at the address above as soon as possible.
Name
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Email
example@example.com
Preferred contact method
Military Preference
Position(s) applied for
Grade Level
Current South Dakota Credentials
Certificate Number
Certificate Expiration
Certified Areas #
Professional Education
Hours above BA
Hours above MA
Name of school
Attended from blanks to blank
Degree
Major or Minor
Name of school
Attended from blanks to blank
Degree
Major or Minor
Name of school
Attended from blanks to blank
Degree
Major or Minor
List up to 3 previous employments with schools - list the most recent first
Please include to/from dates and job title
List up to 3 previous non-school employments - list the most recent first
Please include to/from dates and job title
Please list 3 references, other than relatives and previous employers
Please include their name, posistion, company, phone number, and email
1) Are you able to perform the essential job functions which may or may not require a reasonable accommodation?
2) Can you, after employment, submit verification of your legal right to work in the United States?
3) Have you ever been convicted of any offense, felony or misdemeanor, other than a traffic violation that did not result in suspension or revocation of driver's license?
4) Do you now have any charges against you which have not been adjudicated?
5) Have you ever resigned from or otherwise left a public or private school employment to avoid investigation for alleged misconduct and/or dismissal in South Dakota or any other state or place?
6) Have you ever been dismissed or not reemployed in any probationary or permanent teaching position?
7) Are you now a subject of any injury, disciplinary action, review or investigation, in any district, by a teacher licensing agency, or in the courts of South Dakota or any other state in connection with any alleged misconduct?
8) Have you ever had any credential, application, permit, license, or other document authorizing public school service or teaching suspended, revoked, voided, denied and/or otherwise rejected for cause in South Dakota or in any other state?
9) Is any adverse action now pending against any credential you hold which authorizes public school service or teaching in South Dakota or any other state?
10) Have you ever pleaded guilty, or been convicted or entered a plea of nolo contendere?
State law requires that all applicants prior to employment be fingerprinted and prohibits employment of any person convicted of certain sex offenses, narcotic offenses, and violent crimes.Answering "Yes" to any questions 3-10 above is not an absolute bar to employment.If you answered "Yes" to any questions 3-10 above, fill out the comment box below to explain your answer(s)
Applicants Signature

Clear
Date

MonthDayYear
Date
The Gregory School District is an equal opportunity employer and is non-discriminating in its educational
Should be Empty:

Gregory School District 26-4 Certified Staff Application