Application for Employment

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Position(s) applied for Date of application / /

(If you are applying for a Support Staff Position skip the Certification Section below)

Name Phone

Address

Street Address City/Town Zip

Date of Birth Social Security Number

CERTIFICATION (if applicable) State: Endorsement Area(s)

o Standard o Permanent o Probationary o None

Date Issued Certification: Expiration:

Have you ever had a professional credential or license suspended, revoked or denied? o Yes o No

If the answer to this question is “yes,” provide a complete description of the circumstances, including the type of license or credential, the reason for, and the location and date of the suspension, revocation or denial on the last page of this application.

Position Applying for:

First Choice

________________________________________

Second Choice

EDUCATION:

Name of School & Location. Include High School, College, Graduate (in order)

Dates

Credit Hours

Semester Hours

Post Graduate

Graduate/Under Graduate

Specialization

Degree

Major Minor

An Equal Opportunity Employer

EXPERIENCE: Teaching as well as other for which you received remuneration.

Name of School or Firm & Location

Dates

Nature of Work

Reason for Leaving

Have you ever resigned from a position rather than face disciplinary action? o Yes o No

If the answer to the above question is “yes,” provide on the last page of this application a complete description of the circumstances, including the names of representatives of the employer who are familiar with the circumstances.

Has any disciplinary action been brought against you that resulted in your being discharged from employment?

o Yes o No

If the answer to this question is “yes,” provide a complete description of the circumstances, including the names of representatives of the employer who are familiar with the circumstances on the last page of this application.

List any awards, honors, or recognitions:

Check any of the following which you are willing and able to coach or direct successfully:

o Band

o Chorus

o Golf

o Orchestra

o Softball

o Wrestling

o Baseball

o Cross-Country

o Gymnastics

o Plays

o Tennis

o Yearbook

o Basketball

o Debating

o Hockey

o Skiing

o Track

o Cheerleading

o Football

o Newspaper

o Soccer

o Volleyball

REFERENCES:

Please list those individuals who are qualified to answer questions concerning your fitness for the position you seek. Include especially superintendents, principals, and department heads under whom you have taught. Indicate any to whom you are related.

Name of Individual Title Address/Phone # Related?

Under Act 163 of 1998 a criminal record and background check is a prerequisite to employment, Each applicant will be expected to provide fingerprints, releases and other information necessary to conduct criminal record background investigations. All offers of employment will be conditioned upon completion of the background investigation and a finding that the information provided by the applicant during the pre-employment process was accurate, complete and truthful.

Have you ever been convicted of a crime or misdemeanor? o Yes o No

Have you ever entered a plea of guilty or nolo contendere to a felony or misdemeanor charge?

o Yes o No

Have you ever forfeited a bail bond posted to guarantee your appearance in court to answer criminal charges?

o Yes o No

If the answer to any of the above questions is “yes,” explain the circumstances of the conviction fully on the last page of this application, including the specific charge, date, location of the offense and the court, and disposition of court proceedings.

Intentional failure to fully disclose information related to your criminal conviction record will result in withdrawal of your application from further consideration, or termination of your employment. If nondisclosure is discovered, and you assert that your failure to provide complete details was not intentional, you will be required to show that your failure to disclose resulted from misunderstanding or inadvertence.

Applicant's Statement: I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. The applicant understands that neither this document nor any offer of employment from the employer constitute an employment contract unless a specific document to that effect is executed by the employer and employee in writing. Employment is subject to confirmation of a successful personal investigation by the Vermont Department of Public Safety. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature Date