Teacher Application

Position for which you are applying

Full Name

First NameMiddle NameLast Name

Phone Number

Area CodePhone Number

Home Phone Number

Cell Phone Number

Email Address

High School Name

Years Attended

Graduated?

YesNo

Degree / Major

College Name

Years Attended

Graduated?

YesNo

Degree / Major

Trade or Correspondence School

Years Attended

Graduated?

YesNo

Degree / Major

Teaching Experience (if any)

Please include dates employed, Employer name, address and phone number, Position.

Most recent position

Other Relevant Experience

Please list any other experience you have, including dates, employer name address and phone number, position, salary, supervisor's name and phone number, and reason for leaving.

Experience Description

Please list individuals who are familiar with your professional work and character who may be contacted. Please include their name, position, business phone, home or cell phone.

References

In the field below, please respond to each of the following questions:

1. What brings about your interest to be a Learning Center Supervisor for DLIGR?

2. What experience do you have specific to the position you are applying for and how would you use that experience to be a success?

3. Describe your greatest accomplishments as an educator.

Narrative Response

List degrees, honors, commendations, elective or appointive offices held, or other distinctions received.

HONORS AND DISTINCTIONS

BACKGROUND INFORMATION

Are you, or have you ever been, listed on a sex offender registry?

YesNo

Are you, or have you ever been, listed on a child or dependant adult abuse registry?

YesNo

Have you ever been found guilty, accepted a guilty or Alford Plea, or entered a plea of no-contest for any criminal charge?

YesNo

Have you ever received a deferred judgment, or in some other way had a guilty plea or conviction removed from your record?

YesNo

Have you ever received a deferred judgment, or in some other way had a guilty plea or conviction removed from your record?

YesNo

If you answered “yes” to any of the above questions, provide date, incident, specific charge, city/state in which occurred:

Have you ever been asked to resign from a position, or been given the choice of resigning or being terminated from your position?

YesNo

Have you ever been the subject of an investigation or other formal/informal proceeding that resulted in the termination of your employment or resignation?

YesNo

Have you ever been the subject of an investigation into wrong doing or other formal/informal proceeding, resulting in disciplinary or criminal action?

YesNo

Briefly explain any “yes” response(s):

Responding "yes" to any of the previous questions is not an automatic bar to employment. The date of the offense and the relationship between the offense or infraction and the position for which you are applying will be considered.

Are you legally eligible to work in the United States?

YesNo

Are you able to perform with or without reasonable accommodation, the essential job functions required of the position?

YesNo

Are you currently under contract for any other school/district next year?

YesNo

AGREEMENT (Read carefully before signing or submitting electronically)

By my signature:

• I acknowledge that individuals who provide false, inaccurate, or incomplete information in the application form, in an interview, or any other part of the hiring process or who fail to disclose information requested in the application form, in an interview, or any other part of the hiring process will not be eligible for employment, or, if they are hired, they will be subject to termination.

• I acknowledge that to the fullest extent permitted by state and federal law, DLIGR will consider all information concerning an applicant or an employee in making hiring, termination, and other employment-related decisions. The term "all information" includes information of any kind (verbal, written, photographic, videographic, etc.) that is accessible in any medium (print, electronic, etc.) from any source.

• I acknowledge that DLIGR will consider public information and other information to which it has lawful access. This may include information that is contained in social networking sites, blogs, and other electronic sites, such as YouTube. If there is information that pertains to me that I believe requires explanation, interpretation, or clarification when it is considered, it is my obligation to communicate this information to DLIGR.

• I authorize DLIGR to conduct a complete check regarding my background including, but not limited to, criminal record, child and dependent adult abuse registry screening, and sex offender registry. I agree to prepare and sign any other form necessary to complete a criminal background check. I further authorize all government agencies departments, bureaus, or related entities to release any and all information regarding my criminal history, if any. I agree to immediately notify DLIGR if I should be convicted of any crime while my application is pending, or during my period of employment, if hired.

• I authorize all current and former employers, teachers, and references to release all information regarding my professional competence, performance, character, and background. I waive any right I may have against any person contacted as a reference concerning this application.

• I acknowledge that information that is relevant to DLIGR's decisions will be considered regardless of the date on which DLIGR obtains the information and regardless of the date on which the information was first published, created, or made accessible to DLIGR.

• I understand that if I am employed by DLIGR, this application and associated documents will become part of my permanent record.

• I understand that this application is not a contract of employment. In accepting the position, if hired, I understand that employment is at will, unless otherwise specified by DLIGR. I acknowledge that DLIGR may discharge an at-will employee at any time for any legal reason or no reason at all.

By my electronic submission of this form:

• I attest that all the information contained in this application is accurate, complete, and true.

• I am bound by all elements of the agreement section of the application.

• I understand and accept that electronic submission will be considered equivalent to an original hand written signature on a paper copy of the application.

Date*

Name*

Signature*

Personal Infromation