List names of colleges or universities and the degrees received in order, beginning with the most recent.

List information beginning with current position.

Please list 3 references who may be contacted. 

The term "convicted" includes a guilty plea, a plea of nolo contendere or no contest, a deferred judgement or an adjudication of guilt or delinquency as a minor.

If you answer "yes" to any of the following questions, you must provide detail.

I agree to sign a Waiver authorizing the District to obtain a check of my criminal history, and I further agree to provide all information necessary to obtain this criminal history check. Please provide your date of birth or social security number on the line below so we may obtain your criminal history.

I hereby certify that the information given in this application is correct and true and I authorize the District to obtain a check of my criminal history.

The MOC-Floyd Valley Community School District will not discriminate on the basis of race, color, national origin, gender, disability, religion, creed, marital status, sexual orientation or gender identity.

It is the policy of the MOC-Floyd Valley Community School not to illegally discriminate on the basis of race, color, national origin, gender, disability, religion, creed, marital status, sexual orientation or gender identity in its educational programs, activities, or employment policies as required by Title VI and VII of the 1964 Civil Rights Act, Title IX of the 1972 Educational Amendments, Section 504 of the Federal Rehabilitation Act of 1973 and Section 610 A of the Iowa Code.

It is also the policy of this district that the curriculum content and instructional materials utilized reflect the cultural and racial diversity present in the United States and the variety of careers, roles, and lifestyles open to women as well as men in our society. One of the objectives of the total curriculum and teaching strategies is to reduce stereotyping and to eliminate bias on the basis of sex, race, ethnicity, religion, and disability. The curriculum should foster respect and appreciation for the cultural diversity found in our country and an awareness of the rights, duties, and responsibilities of each individual as a member of a pluralistic society.

Inquiries and grievances regarding compliance with Title IX, Title VI, Section 504 or Section 610 A may be directed to the Superintendent of Schools, PO Box 257, Orange City, Iowa 51041, telephone 712-737-4873; the Director of the Civil Rights Commission, 211 E. Maple, Des Moines, Iowa, telephone 515-281-4121; or the Director of the Region VII Office of Civil Rights, Department of Education, 310 Wisconsin Ave, Ste. 800, Milwaukee, WI 53203-2292, telephone 414-291-1111.