Certified Job Application Form

BARBOURVILLE INDEPENDENT SCHOOL 140 School Street Barbourville, Ky. 40906

CERTIFIED TEACHING APPLICATION
*As of July 13, 1990, all prospective employees are required by Kentucky Law to have obtained a high school diploma or a GED Certificate.*

*Prospective employees will receive consideration without discrimination because of race, creed, color, age, sex, natural origin or disabling condition.*
Date

MonthDayYear
Social Security Number
Birthdate

MonthDayYear
Name*

Last NameFirst NameMiddle Name
Maiden Name (if applicable)
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Cell Phone Number*
Email*
example@example.com
Have you ever been employed by Barbourville Independent School?

YesNo
*If yes, when and under what name and when?
*Were you dismissed for cause?

YesNo
*If yes, please explain
Are you related to the Superintendent or any employee of the Barbourville Independent School?

YesNo
*If yes, to whom , what relation
DESIRED POSITION(S)
EDUCATION
High School
College
Major
Minor
Certificate applied for
Date of application
Certificate now held
Issue date
Expiration date
Type of contract now held, if any
Expiration date
Military: Complete this section if you served in the United States Armed Forces
Branch of Service
Describe you duties and any special training
Period of Active Duty (Month/Year)
Rank at Discharge
Date of Final Discharge
Type of Discharge
Membership in Professional or Civic Organizations (exclude those in which may disclose your race, color, religion or national origin):
Please give complete full-time and part-time employment record. Start with present or most recent employer.
EMPLOYMENT RECORD
Name of Employer
Phone Number
Address
Employed (month/year)
Job Title
Describe work duties
Name of Employer
Phone Number
Address
Employed (month/year)
Job Title
Describe work duties
Name of Employer
Phone Number
Address
Employed (month/year)
Job Title
Describe work duties
If you have ever been employed with a school district or governmental agency, new regulations require the following information.
*Have you ever paid into KTRS?

YesNo
*If you answered Yes to the above question, has your account been withdrawn?

YesNo
REFERENCES
Name
Position
Address
Phone Number
Name
Position
Address
Phone Number
PLEASE NOTE:

For this type of employment, state law requires a criminal record check as a preceding condition of employment.
Have you ever been convicted of or pled guilty to a crime of any nature (including traffic violations) in Kentucky or any other state since you reached the age of 18?

YesNo
*If answered Yes, please explain the charges, state where charged, date(s), whether you were convicted by a court/jury/plea and describe the penalties and fines imposed.
I authorize you to obtain an investigative consumer report containing information obtained through personal interviews with my neighbors, friends, and acquaintances. This report, if obtained, may include characteristics and mode of living. I understand I have the right to make a written request within a reasonable period to receive additional detailed information about the nature and scope of such investigation.

I hereby declare the information provided by me in this application for employment is true, correct, and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application shall be considered cause for dismissal.
Signature

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Date

MonthDayYear
Date
An Official Transcript must accompany this application. Please submit a copy or have a copy mailed to:

Barbourville Independent School

Attention: April Messer

140 School Street

Barbourville, Ky. 40906
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BARBOURVILLE INDEPENDENT SCHOOL 140 School Street Barbourville, Ky. 40906