Street, City, Zip Code

Are you legally able to work in the U.S.?

Have you ever had a professional certificate revoked or suspended?  If yes, please explain

College/University Name

College/University State

Years Attended (example:  2001-2005)

Degree

Subject Area

Total Semester Hours

College/University Name

College/University State

Years Attended (example:  2001-2003)

Degree

Subject Area

Total Semester Hours

College/University Name

College/University State

Years Attended (example: 2001-2003)

Degree

Subject Area

Total Semester Hours

Grade Levels

Subject Areas

Certificate/License Type (example:  5 Year License)

Certificate/License Area

First & Last Name

Full Address (Street, City, State, Zip Code)

Phone Number

First & Last Name

Full Address (Street, City, State, Zip Code)

Phone Number

First & Last Name

Full Address (Street, City, State, Zip Code)

Phone Number

First & Last Name

Full Address (Street, City, State, Zip Code)

Phone Number

Present Title

Full Address

Phone Number

State Date

Name of Supervisor

School Name and Address

School Phone Number

School Assignment

Dates of Employment

Reason for Leaving

School Name and Address

Phone Number

School Assignment

Dates of Employment

Reason for Leaving

School Name and Address

Phone Number

School Assignment

Dates of Employment

Reason for Leaving

The Tuslaw Local School District does not discriminate on the basis of race, color, national origin, age, sex or disability, in admission of access to, or treatment or employment in its programs and activities.  Any person having inquiries concerning the School's compliance with the regulations implementing Title VI of the Civil Rights Act of 1964 (Title VI), Section 504 of the Rehabilitation Act of 1973 (Section 504), or Title II of the Americans with Disabilities Act of 1990 (ADA), may contact the district office.                                                                                                                                                                                                                    Application Confirmation Statement:                                                                                                                                                              It is understood and agreed that the Tuslaw Local School District may contact former employer(s) for verification of my employment history and compliance with the Bureau of Criminal Identification and Investigation (BCI) for a background check and I hereby consent to such inquiries.  I understand that if I am employed prior to the District's receipt of the BCI report and verification of my work experience, my continued employment will be conditioned on:  1) satisfactory work experience as verified by contacts with former employers; and 2) receipt of a report demonstrating that I am in compliance with the Board of Education's rules and regulations and any other legal requirements regarding applicant/employee criminal records and disclosure of convictions.  I further understand that falsification of any and all information on this application shall result in my being disqualified from employment or in my employment being terminated.  By affixing my signature, I agree to the conditions on this application and will, if employed, tender my resignation of employment should I fail to fulfill these conditions.  I agree that any claim or lawsuit relating to my service with Tuslaw Local Schools must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit.  I waive any statute of limitations to the contrary.  I hereby certify that the answers on this application are true and correct to the best of my knowledge and belief and that any deliberate misrepresentation of fact contained herein my be grounds for invalidating my contract commitments resulting from this application.  I understand that my employment will be subject to the laws of the State of Ohio and to the job descriptions and policies adopted by the County/Local Boards of Education.  ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT IS GUILTY OF FALSIFICATION UNDER SECTION 2921.13 OF THE REVISED CODE, WHICH IS A MISDEMEANOR OF THE FIRST DEGREE.