The School Administrative District does not discriminate in the operation of its educational and employment policies and will honor all appropriate laws relative to discrimination.
Date__________________________
Name__________________________ Social Security No.
_______-________-________
Address__________________________________ Phone__________________________
EDUCATION:
Transcripts, including grades, from all college(s)/university(s)
attended must be provided. It is
essential that this section be completed accurately.
No. of Yrs.
College/University Attended Degree
Awarded(if any) Attended
_______________________________ ____________________ _________ _______________
_______________________________ ____________________ _________ _______________
_______________________________ ____________________ _________ _______________
CERTIFICATION:
List certification(s) you hold and provide copies of certification.
Type State Date
Issued Date of Expiration
______________________________ _____________________ __________ ________________
______________________________ _____________________ __________ ________________
______________________________ _____________________ __________ ________________
EXPERIENCE:
Please list previous teaching/substituting experience. Please attach a copy of your resume.
Grade/Subject Position Employer Dates(from/to)
______________ ____________ ________________________________ _________________
______________ ____________ ________________________________ _________________
______________ ____________ ________________________________ _________________
______________ ____________ ________________________________ _________________
AREAS OF INTEREST:
1. Please
indicate grade level(s) at which you are interested in substituting:
K-3________ 4-8________ 9-12_________ Special Education_______ Other______________
2. If you are
interested in substituting at the elementary level and have a specialty area,
please circle the
3.
If you are interested in substituting at the junior
high or high school level. Please indicate the specific
Subject areas:_______________________________________________________________________
REFERENCES: Please provide three references who are not
related to you who are familiar with your work as a teacher, substitute or who
know of your experience working with youth.
Name Address Telephone
_______________________________ _________________________ ________________________
_______________________________ _________________________ ________________________
_______________________________ _________________________ ________________________
BACKGROUND:
Have you ever been disciplined,
discharged, or asked to resign from a prior position? Yes____ No____
Have you ever resigned from a
prior position after a complaint had been received
Against you or your conduct was
under investigation or review? Yes____No____
Has your contract in a prior
position ever been non-renewed? Yes____No____
Have you ever not been nominated
for re-employment in a prior position or ever
had your nomination
for re-employment not be approved? Yes____No____
Have you ever been charged with or
investigated for sexual abuse or harassment of
another person? Yes____No____
Have you ever been convicted of a
crime (other than a minor traffic offense)? Yes____No____
Have you ever entered a plea of
guilty or “no contest” (nolo contendere)
to any crime
(other
than a minor traffic offense)? Yes____No____
Have you ever had a professional
license or certificate suspended or revoked in any
State, or have you ever
voluntarily surrendered, temporarily or permanently,
professional license or
certificate in any state? Yes____No____
Has any court ever deferred, filed
or dismissed proceedings without a finding of guilty
and required
that you pay a fine, penalty or court costs and/or imposed a requirement
as to your
behavior or conduct for a period of time in connection with any crime
(other
than a minor traffic offense)? Yes____No____
If you have answered YES to any of the previous questions,
provide full details below including, with respect to court actions, the date,
offense in questions, and the address of the court involved. Attach additional sheets if necessary. Conviction or other disposition of a crime is
not necessarily an automatic bar to employment.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SIGNATURE STATEMENT:
My signature below constitutes authorization to check my
employment history, including without limitation, criminal arrest and
conviction record checks, reference checks, and release of investigatory
information possessed by any state, local or federal agency. I further authorize those persons, agencies
or entities that SAD #4 contacts in connection with my employment application
to fully provide SAD #4 any information on the matters set forth above. I 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 I might otherwise have against
SAD#4 its agents and officials or against any provider of such information.
I understand that information submitted in and with this
application may be disclosed to a screening and/or interviewing committee,
which may include board members, administrators, other staff, and members of
the community. I give my consent to this
disclosure.
SIGNATURE:________________________________________________
APPLICATION FOR SUBSTITUTE TEACHING POSITION CHECK
LIST: The completed employment
application cannot be evaluated unless all of the following materials have been
provided.
________ Application form fully completed
________ Copies of Transcript(s) if any
________ Copy of
________ YES to any of the questions in the
Background section explained
________ Application signed
NOTE: ALL APPLICATION MATERIALS BECOME THE PROPERTY
OF SAD #4. NONE WILL BE RETURNED. PROVIDING ANY FALSE OR MISLEADING INFORMATION
ON THIS APPLICATION OR IN THE APPLICATION OR EMPLOYMENT SCREENING PROCESS SHALL
BE FULLY SUFFICIENT GROUNDS TO REFUSE TO EMPLOY THE APPLICANT OR, IF THE
APPLICANT HAS BEEN EMPLOYED, TO IMMEDIATELY DISMISS THE APPLICANT/EMPLOYEE.