CERTIFIED PERSONNEL APPLICATION FORM

UNIFIED SCHOOL DISTRICT NO. 112

PO Box 176

Claflin, KS 67525

(620) 588-4200

Bobby Murphy, Superintendent
CERTIFIED PERSONNEL APPLICATION FORM
Each applicant for a position with the USD 112 Central Plains must complete this form. It is important to follow the directions and answer all items completely and correctly. If an applicant is appointed and accepts a position the information given herein will become a part of the person's professional record. The amount of space provided for answering some items is necessarily and purposely limited, we suggest you word your answers to these items carefully.
Position you wish to apply for:
Last
First
Middle
Street/PO Box
City
State
Zip
Permanent Address: City Name and telephone number of person who will know where to contact you:
Street/PO Box
City
State
Zip
Last
First
Middle
City
State
Zip
Telephone
Format: (000) 000-0000.
Date of graduation or last attendance
Under Graduate
Major
Dates of Attendance

MonthDayYear
Date
Graduate
Major
Dates of Attendance

MonthDayYear
Date
Choose one to indicate your college hours:
List any awards you have received, or college, civic, or educational activities in which you have participated. Award/ActivityDescription
LICENSURE
Kansas License
Other State License(s)
Level
Subject Areas
Have you ever been denied Kansas Certification?
If you do not have Kansas Certification, have you made application?
Professional Experience

(List your most recent experience first)
Name and Location of School
Dates
Name of Supervisor
E-mail of Supervisor
example@example.com
Name and Location of School
Dates
Name of Supervisor
E-mail of Supervisor
example@example.com
Name and Location of School
Dates
Name of Supervisor
E-mail of Supervisor
example@example.com
May we contact the supervisors above?
If no, indicate which one(s) you do not wish us to contact.
From
Other Work Experience
Name and address of Work
Dates
Type of Business
Name of Supervisor
E-mail of Supervisor
example@example.com
Name and address of Work
Dates
Type of Business
Name of Supervisor
E-mail of Supervisor
example@example.com
May we contact the supervisors above?
If no, indicate which one(s) you do not wish us to contact.
Please write your responses to each question.
1. Why do you want to be a professional educator?
2. Why do you desire this position with the USD 112 School System?
3. What do you see as your greatest asset(s) as an educator?
4. Is there anything else you would like us to know about you that is not covered in this application?
If employed, I will comply with the rules and regulations set forth and communicated to an employee by the Board of Education. I understand misrepresentation of any facts in this application could result in my termination from employment.
Signature

Clear
Date

MonthDayYear
Date
USD 112 does not discriminate on the basis of sex, race, color, national origin, handicap, or age in admission or access to, or treatment or employment in. its programs or activities. Questions regarding compliance with the Title IV. Title IX. or Section 504, including information concerning location of services, activities, and facilities that are accessible to and usable by disabled persons may be directed to the superintendent, Bobby Murphy. (620) 588-4200, USD 112 Central Plains
Email
example@example.com
Should be Empty:

CERTIFIED PERSONNEL APPLICATION FORM

LICENSURE

Professional Experience

Other Work Experience