Certified Application

CERTIFIED APPLICATION

SOUTHWEST PARKE COMMUNITY SCHOOL CORPORATION
Date*

MonthDayYear
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail
POSITION
Position you are applying for:*

Elementary TeacherJr High TeacherHigh School TeacherOther (i.e. Counselor)
Elementary Grade Level Preference*

KDGGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6CounselorSpecial EducationSpecial ServicesNot Applicable
Secondary Level Subject Preference*

AgBand/ChoirBusinessCounselorLanguage ArtsMathPhysical EducationScienceSpecial EducationSpecial ServicesNot Applicable
List any major teaching endorsements
Are you currently under contract?*

YesNo
If "Yes", when does your contract expire?
May we contact your current employer?*

YesNo
If "Yes", please provide their contact information.
EDUCATION
Please list your secondary and post secondary education information.
Secondary Education Information
Post Secondary Education Information
Please list awards and/or certificates:
Please describe your community service affiliations, if any:
LICENSURE
Please list your licensure information:
Expiration Date

MonthDayYear
Degree(s) Check all that apply*

B.S.B.A.M.S.M.A.Ed. S.Ed. D.Ph. D.
TEACHING EXPERIENCE

List all experience chronologically for the past 10 years, beginning with the most recent. Include and identify student teaching experience.
Dates (format mm/yyyy to mm/yyyy)
School district's name & address
School's name
Grade level(s) and/or subject(s) taught
Reason for leaving
Dates (format mm/yyyy to mm/yyyy)
School district's name & address
School's name
Grade level(s) and/or subject(s) taught
Reason for leaving
Dates (format mm/yyyy to mm/yyyy)
School district's name & address
School's name
Grade level(s) and/or subject(s) taught
Reason for leaving
NON TEACHING EMPLOYMENT EXPERIENCE
Dates (format mm/yyyy to mm/yyyy)
Employer's name & contact information
Type of work performed
Reason for leaving
Dates (format mm/yyyy to mm/yyyy)
Employer's name & contact information
Type of work performed
Reason for leaving
MILITARY EXPERIENCE
Branch of Service

Air ForceAir National GuardArmyMarinesNavy
Rank
Years of Military Service
Months of Active Duty
REFERENCES

Please do not include relatives
Reference #1 (Name & Contact Information)
Reference #2 (Name & Contact Information)
Reference #3 (Name & Contact Information)
HISTORY & LIMITATIONS
Are you presently being investigated or under procedure to consider your discharge for misconduct by your present employer or if you offered a resignation to your previous employer?*

YesNo
If you answered "Yes", please provide information explaining the circumstances
Have you ever been reprimanded, disciplined, discharged, or asked to resign from a prior position?*

YesNo
If you answered "Yes", please provide information explaining the circumstances
Have you ever resigned from a prior position without being asked, but under circumstances involving your employer's investigation of sexual contact with another person, of mishandling funds, or of criminal conduct?*

YesNo
If you answered "Yes", please provide information explaining the circumstances
Have you ever been charged with or investigated for sexual abuse or another person?*

YesNo
If you answered "Yes", please provide information explaining the circumstances
Have you ever been charged with, pleaded guilty or "no contest" to, or been convicted of any crime involving sexual abuse of any person or any crime of moral turpitude?*

YesNo
If you answered "Yes", please provide information explaining the circumstances
Have you ever been convicted of a crime, other than a minor traffic offense, ever entered a plea of not guilty or a plea of "no contest", or has any court ever deferred further proceedings without entering a finding of guilty and placed you on probation, for any crime other than a minor traffic offense? *

YesNo
If you answered "Yes", please provide information explaining the circumstances
CONVICTION OF A CRIME IS NOT AN AUTOMATIC BAR TO EMPLOYMENT. THE DISTRICT WILL CONSIDER THE NATURE OFTHE OFFENSE, THE DATE OF THE OFFENSE, AND THE RELATIONSHIP BETWEEN THE OFFENSE AND THE POSITION FOR WHICH YOU ARE APPLYING.
ATTEST & SIGN
I understand that if I am hired by SWPCSC, I will be obligated to provide information for an Expanded Criminal Background Check. I agree to pay all fees associated with this background check.
I certify that all statements made heron are true and correct to the best of my knowledge. I understand that any false statements made on this application may be cause for non-employment or for dismissal if employed.
Any false or misleading information on this application shall be fully sufficient grounds to refuse to employ or, having been employed, shall be immediate grounds for dismissal. Your signature below constitutes authorization to check your employment history, including without limitation, evaluations, criminal arrest and conviction record checks, and release of investigatory information possessed by any private or public employer or any state, local or federal agency. You further authorize those persons, agencies or entitites that the Southwest Parke Community School Corporation contacts in connection with your employment application to fully provide the Southwest Parke Community School Corporation any information on the matters set forth above. You expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that you might otherwise have against Southwest Parke Community School Corporation, its agents and officials or against any provider of such information.
Please type your name
Date of application

MonthDayYear
Should be Empty:

CERTIFIED APPLICATION

POSITION

EDUCATION

LICENSURE

TEACHING EXPERIENCE

NON TEACHING EMPLOYMENT EXPERIENCE

MILITARY EXPERIENCE

REFERENCES

HISTORY & LIMITATIONS

ATTEST & SIGN