Application Date:
02/09/2010
Date Available:
Name:
Current Street Address :
Current City St Zip :
Current Home Phone:
Work Phone:
Cell Phone:
Permanent Street Address :
Perm City St Zip :
Permanent Phone:
Email:
Are you a U.S. Citizen?
Are you eligible to work in the United States?
Position(s) for which you are applying:
Salary Expected:
Are you available full time?
Are you willing to work less than full time?
Are you under a teaching contract for next year?
Where?
How did you learn of this opening?
EDUCATION:
College:
Location:
Number of Hours Beyond Highest Degree:
Degree Earned (Include Major & Minor Fields):
Dates Attended/Graduated:
College:
Location:
Number of Hours Beyond Highest Degree:
Degree Earned (Include Major & Minor Fields):
Dates Attended/Graduated:
College:
Location:
Number of Hours Beyond Highest Degree:
Degree Earned (Include Major & Minor Fields):
Dates Attended/Graduated:
College:
Location:
Number of Hours Beyond Highest Degree:
Degree Earned (Include Major & Minor Fields):
Dates Attended/Graduated:
High School:
Location:
* Candidates must be able to meet the requirements for Iowa licensure.
Do you currently hold an Iowa Teacher's License?
Iowa Folder Number:
Have you applied for your Iowa Teacher License?
Do you hold a license from another state?
If so, which state(s)?
What certifications, endorsements or approvals have you obtained?
Education and/or other Employment
(begin with current/most recent) * Applicants may include paid or volunteer activities
other than classroom instruction/support activities
and new practitioners should include student teaching and other field experiences.
School District/Employer:
Salary:
Address:
Supervisor's Name:
Phone:
Dates of Experience:
to
Position:
Full-time?
If no, number of workdays each year if employed part-time or less than 6 months.
Duties and Responsibilities:
Reason for Leaving:
If presently employed, may we contact your employer for references?
May we contact you at your place of employment?
School District/Employer:
Salary:
Address:
Supervisor's Name:
Phone:
Dates of Experience:
to
Position:
Full-time?
If no, number of workdays each year if employed part-time or less than 6 months.
Duties and Responsibilities:
Reason for Leaving:
School District/Employer:
Salary:
Address:
Supervisor's Name:
Phone:
Dates of Experience:
to
Position:
Full-time?
If no, number of workdays each year if employed part-time or less than 6 months.
Duties and Responsibilities:
Reason for Leaving:
School District/Employer:
Salary:
Address:
Supervisor's Name:
Phone:
Dates of Experience:
to
Position:
Full-time?
If no, number of workdays each year if employed part-time or less than 6 months.
Duties and Responsibilities:
Reason for Leaving:
School District/Employer:
Salary:
Address:
Supervisor's Name:
Phone:
Dates of Experience:
to
Position:
Full-time?
If no, number of workdays each year if employed part-time or less than 6 months.
Duties and Responsibilities:
Reason for Leaving:
School District/Employer:
Salary:
Address:
Supervisor's Name:
Phone:
Dates of Experience:
to
Position:
Full-time?
If no, number of workdays each year if employed part-time or less than 6 months.
Duties and Responsibilities:
Reason for Leaving:
MILITARY:
Active Duty:
to
Branch:
Location of Duty:
Rank at Discharge:
Type of Discharge:
Reserve Duty:
to
Branch:
Obligation:
Times of Current Training Duty:
REFERENCES:
List at least three who have evaluated your practitioner skills and abilities.
Name:
Work Phone:
Address:
Home Phone:
Employer:
Position:
Name:
Work Phone:
Address:
Home Phone:
Employer:
Position:
Name:
Work Phone:
Address:
Home Phone:
Employer:
Position:
Name:
Work Phone:
Address:
Home Phone:
Employer:
Position:
Have you previously held a licensed position in an Iowa public school?
Name of District(s)?
If yes, have you successfully completed an official probationary period
in a public school district?
If yes, what was the length of the probationary period?
Are you on a sex offender registry?
Are you on the Department of Human Services' child abuse registry?
Have you ever been convicted of a felony or misdemeanor (excluding traffic violations)?
If yes, please provide date, incident, city / state of charge:
Responding "yes" to any of the previous questions is not an automatic bar to employment.
Are you able to perform, with or without reasonable accommodation, the essential job functions required of this position?
If no, please explain:
AGREEMENT
I hereby certify that the above information, to the best of my knowledge, is true, accurate and complete.
Any misrepresentation or willful omissions of fact shall be sufficient cause for disqualification of this application or termination of employment.
I authorize verification of any application information.
I authorize all persons and current and former employers to release any information concerning my background.
I understand that this application is not a contract of employment.
I also understand that if hired, regardless of any oral representation to the contrary, the employment is terminable-at-will.
A typed name shall constitute a signature.
Signature:
Date:
Note: 1. The application is considered complete when all of the following have been received:
a) completed application form, b) resume,
OPTIONAL QUESTIONNAIRE
The Grant Wood Area Education Agency assured Equal Employment Opportunity in all its policies
regarding recruiting, hiring, promotions, and transfers, compensation and other benefits,
training, and layoff and recall practices. Our Agency believes that special measures and
extraordinary effort are required to prevent discrimination and eliminate it within the
organization. We pledge ourselves to a determined and sustained effort in support of this belief.
The Agency must also comply with requirements of reporting affirmative action to city, state,
and federal governments. Thus the reason for the optional questionnaire, we need your assistance
to insure our reports are accurate.
The information contained thereon will be classified as strictly confidential.
Should you have any questions, please don't hesitate to call the Human Resources Office.
REMEMBER, completion of this form is optional! None of the information
that you submit will appear on any application information or be used outside of the
Human Resources Office.
OPTIONAL CONFIDENTIAL QUESTIONNAIRE
Birthdate:
Sex:
Minority Code:
Disability:
