CERTIFIED APPLICATION

Collinsville Public Schools

1902 West Maple

Collinsville, OK 74021

(918) 371-2326

"An Equal Opportunity Employer"
CERTIFIED APPLICATION
NOTICE TO APPLICANT:

Independent School District #I-6 of Tulsa County, Oklahoma, does not knowingly discriminate against any employee or applicant for employment on the basis of race, color, sex, pregnancy, gender, gender expression or identity, national origin, religion, disability, veteran status, sexual orientation, age, or genetic information. This policy encompasses recruitment, selection, assignment, promotion, transfer, termination, compensation, training and apprenticeship and all other terms, conditions, benefits and privileges associated with employment. This policy also extends to the educational programs and activities operated by the District.

Discrimination is specifically prohibited by Title IX of the Education Amendments of 1972, as amended, and Title 45, Subtitle A, Part 86, of the impending regulations administered by the Director of the Office of Civil Rights of the United States of Health, Education and Welfare.
FIELDS MARKED BY AN ASTERISK ARE REQUIRED FOR YOUR APPLICATION TO BE SUBMITTED
I. PERSONAL DATA
Today's Date *
Name *

First Name Middle Name Last Name
Date of Birth (optional)

Month Day Year
Phone Number *

Area Code Phone Number
E-mail Address *
Present Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
II. POLICY STATEMENTS AND QUESTIONS
1. Interiews will be arranged by the personnel office. You will receive no further reply unless you are being actively considered for a specific position.

2. This application will remain on file for one year. It must be renewed at that time, if so desired.

3. Each applicant should edit the data provided most carefully before submitting this form to the personnel office.
Do you agree to provide information regarding citizenship status as required by law? *

Yes No
Please select one of the boxes below regarding any legal action you may have faced. *

Entered a plea of guilty or nolo contendere to a state (any state) or federal felony charge Been convicted of a state (any state) or federal felony offense Been charged with a state (any state) or federal felony offense with was reduced to a misdemeanor offense to which you entered a plea of guilty or nolo contendere Entered a plea of guilty or nolo contendere to, or been convicted of, a state (any state) or federal misdemeanor charge involving illegal chemical substances or illegal sexual activity Entered into a deferred prosecution agreement with a state (any state) or federal prosecutor NONE
If you answered yes to any of the above questions, please list type of violation, date, place (city and state) and an explanation of incident.
III. FIELDS OF SERVICE PREFERRED
FIRST CHOICE - GRADE *

ECC (PK-K) Herald Elem. (1-3) Upper Elem. (4-5) Middle School (7-8) Wilson (6) High School (9-12)
FIRST CHOICE - SUBJECT *

ADMINISTRATION ELA GEOGRAPHY MATH SOCIAL STUDIES SCIENCE HISTORY PHYSICAL ED ART SPECIAL EDUCATION DISTRICT NURSE
SECOND CHOICE - GRADE *

ECC (PK-K) Herald Elem. (1-3) Upper Elem. (4-5) Middle School (7-8) Wilson (6) High School (9-12)
SECOND CHOICE - SUBJECT *

ADMINISTRATION ELA GEOGRAPHY MATH SOCIAL STUDIES SCIENCE HISTORY PHYSICAL ED ART SPECIAL EDUCATION DISTRICT NURSE
Interest in Coaching or Sponsoring Extracurricular Activies

Yes (Please select below based on ability, interest, and experience) No
Athletics

Cross Country Baseball Track Basketball Tennis Wrestling Weight Lifting Golf Football Volleyball Soccer Cheerleading
Fine Arts

Instrumental Music Speech/Debate Choral Music Drama
Literacy

School Newspaper School Yearbook
Organizations

Student Government Class Sponsor Club Sponsor
IV. INSTITUTIONS OF HIGHER LEARNING ATTENDED
Institution
Location
Dates Attended
Degree & Year Conferred
Institution
Location
Dates Attended
Degree & Year Conferred
CERTIFICATION
Please list Certification(s), Date of Issuance, Date of Expiration
V. EXPERIENCE IN SCHOOL WORK
Experience in school work, as requested hereunder, should include only teaching or administrative experience in a duly accredited private or public school, college or university, on a regular full-time basis as accepted by the Oklahoma State Department of Education. Do not include part-time substitute or student teaching experiences.
School Name
Location
Dates Worked
Subject / Grade Taught or Assignment
School Name
Location
Dates Worked
Subject / Grade Taught or Assignment
VI. STUDENT TEACHING EXPERIENCE
Did you do any student teaching? *

Yes No (skip this section)
School Name
Location
Dates
Subject / Grade Taught or Assignment
Supervisory Teacher
VII. MISCELLANEOUS
List membership in professional organizations:
If not currently employed in a teaching position for a year or more, state where and how you have been occupied during this interval. (give locations and dates):
Name and location of high school from which you graduated: *
Are you in any way related to an employee of Collinsville Public Schools or a member of the Collinsville Board of Education? *

Yes No (skip this section)
If yes, please indicate who, their present position, and your relationship to that individual
VIII. REFERENCES
Name (and Company / Postion, if applicable) *
Phone Number *
Years Known *
Name (and Company / Postion, if applicable) *
Phone Number *
Years Known *
Name (and Company / Postion, if applicable) *
Phone Number *
Years Known *
IX. SCHOOL SERVICE
In your own words, please express your views as to why and how you could be a successful member of the Collinsville Public Schools staff. Your remarks should be limited to the space provided below. *
In order that the officials of the Collinsville Public Schools may be fully informed as to my personal character and qualifications for employment, I hereby authorize Collinsville Public Schools to contact any former employer or other person whom they wish to contact concerning my personal character and qualifications and I hereby release such persons and Collinsville Public Schools from any and all liability for information provided or obtained as a result of the inquiries.

I understand that any false information or misrepresented information contained in this application may be grounds for my immediate termination.

Typing your name in the box below indicates you agree the electronic signature is the legal equivilant of your manual signature on this application.
Electronic Signature *
Date *
We are currently unable to accept resumes and certificates attached to this application. If you are being actively considered for a position, we may request those items at that time.
Should be Empty:

I. PERSONAL DATA

II. POLICY STATEMENTS AND QUESTIONS

III. FIELDS OF SERVICE PREFERRED

IV. INSTITUTIONS OF HIGHER LEARNING ATTENDED

V. EXPERIENCE IN SCHOOL WORK

VI. STUDENT TEACHING EXPERIENCE

VII. MISCELLANEOUS

VIII. REFERENCES

IX. SCHOOL SERVICE