APPLICATION FOR A CERTIFICATED POSITION

BLOOMFIELD R-14 SCHOOL DISTRICT

505 COURT STREET, P.O. BOX 650

BLOOMFIELD, MO 63825

573-568-4564

The Bloomfield R-14 School District is an equal opportunity employer. The School District considers applicants for all positions with out regard to race, color, religion, sex, national origin or disability. If you have a disability or handicap which may require accommodation for you to participate in our application process (including filling out this form, interviewing or any other pre-employment procedure or requirement), please make us aware of any accommodation you feel is necessary. If you have any inquiries, complaints or concerns about any pre-employment procedure or requirement, including completing this application, or about the District policy of non-discrimination, you may contact the superintendent of schools at 573-568-4564.

All applicants are expected to answer all questions on this application. Answer “none” or “not applicable” where necessary.

Date ____________________

__________________________________________________________________________________________

Last Name First Name Middle Name

Other names that may appear on your transcripts or records:

__________________________________________________________________________________________

Social Security Number ________-________-__________

Address: ___________________________________________________________________________

Street City Zip

Current Phone # (_____)_______-________

Date Available ________________________________________

Certification: Type ______________________________ (Life, PC1, Etc.) Other _______________________

State _________________________________________ Subject(s) __________________________________

Grade Level(s) _______________________________ Expiration Date(s) ______________________________

Other information regarding your Certification and/or certification status: ______________________________

__________________________________________________________________________________________

Position(s) for which you are applying: _________________________________________________________

Subject(s) ________________________________________________________________________________

Grade Level(s) _____________________________________________________________________________

Are you available for substitute teaching? __________ Paraprofessional? _____________________________

Extra duty positions you may be interested in sponsoring or coaching: _________________________________

__________________________________________________________________________________________

Educational Preparation:

	Name & Location	Dates of Attendance	Name of Degree	Major	Overall GPA
High School
Colleges / Universities

Teaching Experience (If none, list student teaching experience):

District Name & Location	Position	Dates of Employment	Numbers of Years	Supervisor	Phone

Other Work Experience:

Employer Name & Location	Position	Dates of Employment	Number of Years	Supervisor	Phone

References:

Name	Address	Phone	Positon

Employment Questions:

1. Have you ever been arrested for, or charged with or convicted of a felony or misdemeanor? (Exclude traffic offenses for which you were not sentenced to jail or for which the fine was less than $100.00. _________________________________________________________________________

2. Have you ever pleaded guilty or no contest to a felony or misdemeanor? (Exclude traffic offenses for which you were not sentenced to jail or for which the fine was less than $100.00) _________________________________________________________________________________

3. Has the Missouri Division of Family Services or a similar agency in any other state or jurisdiction, ever issued a determination or finding of cause or reason to believe or suspect that you have engaged in physical, emotional, psychological or sexual abuse or neglect of a child? _________________________________________________________________________________

4. Have you ever failed to be re-employed by an educational institution? ________________________

If the answer to any of the foregoing questions is “yes” please explain; use a separate sheet if necessary:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

READ CAREFULLY BEFORE SIGNING

I acknowledge and agree to the following provisions as conditions to consideration of my application for employment:

1. I hereby authorize my current and former employers and references to furnish any information about me and about my work experience. I release my current and former employers and references from any and all liabilities or damages of any nature as a result of providing such information. My current and former employers and references may rely on a signed copy of this release.

2. I understand and consent to having criminal and arrest records checks as well as background checks by the Missouri Division of Family Services as a condition for consideration of may application for employment.

3. I certify that the answers given in this application are true and complete to the very best of my knowledge. In the event I am employed by the District and in the further event that I have provided false or misleading information in this application or in a subsequent employment interviews, I understand that my employment may be terminated at any time after discovery of the false or misleading information.

4. I understand that this application will be considered active during the school year in which it was submitted. I understand that if I wish my candidacy to remain open after that date I must submit another application.

_______________________________________________________ ________________________

Signature Date