Certified Application
Position Applying For
Personal Information
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Are you legally eligible to work in the United States
Please Select
Yes
No
License Information
Do you have an Iowa Teaching Certificate?
Please Select
Yes
No
If No, have you applied for your Iowa Teacher License?
Please Select
Yes
No
IA Folder Number
Do you hold a license from another state?
Please Select
Yes
No
If yes, which state(s)
Are you currently under contract with any school district?
Please Select
Yes
No
If yes, which school district?
Are you under a teaching contract for next school year?
Please Select
Yes
No
If yes, where?
What certificates, endorsements or approvals have you achieved (including coaching authorizations)?
Are you able to perform, with or without reasonable accommodation, the essential job functions required of this position?
Please Select
Yes
No
If no, please explain
Previous Education Experience
Have you previously held a licensed position in an Iowa public school?
Please Select
Yes
No
If Yes, which District?
Have you successfully completed an official probationary period in a public school district?
Please Select
Yes
No
If Yes, what was the length of the probationary period?
Have you successfully completed a mentoring and induction program?
Please Select
Yes
No
If Yes, when?
If no, have you completed:
Please Select
One year
Two years, but have been recommended for a third year
Three years and am not being recommended for a professional license
None
Education
Highest Degree Achieved
Education Details
Dates Attended
Location
Degree
Major
Minor
Did you graduate?
High School
College/University
College University
Previous Employment
School District/Employer
Address
Supervisor Name
Supervisor Phone Number
Supervisor Email Address
Dates Worked: From - To
If school district, enrollment
Position
Duties
Reason for leaving
School District/Employer
Address
Supervisor Name
Supervisor Phone Number
Supervisor Email Address
Dates worked: From - To
If school district, enrollment
Position
Duties
Reason for Leaving
School District/Employer
Address
Supervisor Name
First Name
Last Name
Supervisor Phone Number
Please enter a valid phone number.
Supervisor Email
example@example.com
Dates worked: From - To
If school district, enrollment
Position
Duties
Reason for leaving
Military Experience - Complete only if applicable
Have you served in the Military?
Please Select
Yes
No
Branch
Dates served: From - To
Type of Discharge
Rank at Discharge
Other Information
Language Information
Do you know any language other than English?
Please Select
Yes
No
Language(s)
Oral Level
Written Level
References
Reference Name
First Name
Last Name
Employer & Position
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Reference Email
example@example.com
Reference Name
First Name
Last Name
Employer & Position
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Reference Email
example@example.com
Reference Name
First Name
Last Name
Employer & Position
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Reference Email
example@example.com
Reference Name
First Name
Last Name
Employer & Position
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Reference Email
example@example.com
Background Information
Responding "yes" to any of the below questions is not an automatic bar to employment. The date of the offense, and the relationship between the offense and the position for which you are applying will be considered.
Are you on the sex offender registry?
Please Select
Yes
No
Are you on the Department of Human Services' child abuse registry?
Please Select
Yes
No
Have you ever been convicted of an offense other than a minor traffic violation?
Please Select
Yes
No
DUI & DWI convictions are not minor and must be reported
Have you ever been arrested, charged, or convicted of a felony?
Please Select
Yes
No
Have you have been arrested, charged, or convicted for a sex-related offense?
Please Select
Yes
No
Even if no contest, charges dropped or pled down.
Have you have been arrested, charged, or convicted for a drug-related offense?
Please Select
Yes
No
Even if no contest, charges dropped or pled down.
If yes to any of the above, please provide date, incident, city/state & charge.
Questions
Why are you seeking a position in this district?
What is your vision for teaching and learning in the 21st century?
What are your major personal attributes as an educator which may be an asset to this position?
Are there any other significant items of information you wish to share?
Additional Documentation
Cover Letter
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Background Check Consent
I authorize the MOC-Floyd Valley School District to obtain a check of my background including my criminal history and fingerprints, if applicable, and I further agree to provide all information necessary to obtain this background check and fingerprints, if applicable.
Signature
Date
-
Month
-
Day
Year
Date
Application Verification
I hereby certify that the above information, to the best of my knowledge, is true, accurate and complete. Any misrepresentation or willful omissions of fact shall be sufficient cause for disqualification of this application or termination of employment. I authorize verification of any of this information. I authorize all current and former employers to release any information concerning by background. I understand that this application is not a contract of employment. I also understand that if hired, regardless of any oral representation to the contrary, the employment relationship is terminable-at-will.
Signature
Date
-
Month
-
Day
Year
Date
Equal Equity Policy Statement
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 Section610 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 Equity Coordinator, MOC-Floyd Valley Community School District, Orange City, IA 51041 ; the Director of the Civil Rights Commission, 6200 Park Avenue, Suite 100, Des Moines, Iowa, 50321-1270, 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.
The MOC-Floyd Valley Community School District is an EEO/AA employer.
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