The School District considers applicants for all positions without 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 the 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 Administration at the above address. 

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

First Name          

Last Name          

Middle Initial      

Street Address    

Address (cont.)   

City                     

State/Province     AK AL AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip/Postal Code  

Country               

Work Phone       

Home Phone       

E-mail                 

What type of employment do you wish to be considered for?

Full-time
Part-time

When would you be available for employment?

-- mm/dd/yy

Certificates

#1

State AK AL AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA RI SC SD TN TX UT VT VA WA WV WI WY Certification Type Area Subject

Grade Level(s)   Expiration Date: mm/dd/yyyy

Other information regarding your certificate

#2

State AK AL AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA RI SC SD TN TX UT VT VA WA WV WI WY Certification Type Area Subject

Grade Level(s)   Expiration Date: mm/dd/yyyy

Other information regarding your certificate

#3

State AK AL AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OR PA RI SC SD TN TX UT VT VA WA WV WI WY Certification Type Area Subject

Grade Level(s)   Expiration Date: mm/dd/yyyy

Other information regarding your certificate

(If additional certificates, send detailed information in an email to wbrock@clarksburg.k12.mo.us. Put Certified Application in the subject line and your full name and address in the body of the email along with the certificate information.)

Position(s)

If you are applying for more than one position, list separating with a comma.

Position(s) for which you are applying:

Subject(s): Grade Level(s):

Are you available for substitute teaching? Yes No Paraprofessional? Yes No

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

Educational Preparation

Name & Location

Dates of attendance

Type of degree

Major

Overall GPA

High School               N/A               N/A                  N/A

College              

College              

College              

(If additional college information, send detailed information in an email to wbrock@clarksburg.k12.mo.us. Put Certified Application in the subject line and your full name and address in the body of the email along with the college information.)

 

Teaching Experience (If none, list student teaching experience)

List the most recent first

District Name & Location & Phone

Position

Dates of employment

Number of years

Supervisor Name & Title

                                 

                                 

                                

                                

(If additional teaching experience, send detailed information in an email to  wbrock@clarksburg.k12.mo.us. Put Certified Application in the subject line and your full name and address in the body of the email along with the teaching experience information.)

Other Work Experience

List the most recent first

Name & Location

Position

Dates of employment

Number of years

Supervisor Name & Title

Phone

                     

                     

                     

(If additional work experience, send detailed information in an email to  wbrock@clarksburg.k12.mo.us. Put Certified Application in the subject line and your full name and address in the body of the email along with other work experience information.)

References

Name

Address

Phone

Position

                                  

                             

                            

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) Yes No

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) Yes No

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? Yes No

4. Have you ever failed to be re-employed by an educational institution? Yes No

If the answer to any of the foregoing questions is "yes", please explain:

READ CAREFULLY BEFORE SUBMITTING

I acknowledge and agree to the following provisions as condition 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 arrest records checked as well as my background checked by the Missouri Division of Family Services as a condition for consideration of my 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 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 through April 30th of the current school year.  I understand that if I wish my candidacy to remain open after that date, I must submit another application.

I have read and agree to the conditions and with the statements above.  Date: mm/dd/yyyy

You may print this application before submitting.