Long Beach School District Employment Application FOR LICENSED POSITIONS

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1 Long Beach School District Employment Application FOR LICENSED POSITIONS NAME: LAST FIRST M.I. SOCIAL SECURITY NUMBER: HOME PHONE: WORK PHONE: Note : Before you can be recommended to the School Board for employment, you shall have furnished to us: ADDRESS: STREET or PO BOX 1. A completed employment application 2. Transcripts of all college work 3. References 4. NTE and / or PRAXIS Scores 5. Original Mississippi teaching certificate or permit properly endorsed in the area for which you have applied 6. A recent photograph of yourself. If an employee leaves the Long Beach School District before working at least six month, (from the date fingerprinted) a fee of $50.00 will be deducted from the employee s last pay check. CITY STATE ZIP APPLICANT NOTE This application form is intended for use in evaluating your suitability for employment. It is not an employment contract. Please answer all appropriate questions completely and to the best of your ability. False or misleading statements are grounds for refusal or termination of employment and benefits. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, age, creed, national origin, or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. MARK APPROPRIATE BOXES New Application Previous Application on File Former Employee of Long Beach School District Full-Time Part-Time Substitute INDICATE POSITION(S) DESIRED FOR WHICH YOU ARE LICENSED Teacher Administrator Guidance K - 6 Librarian 7-12 Other (Explain)

2 GENERAL INFORMATION: Are you presently under contract? Yes No If yes, where? Present position _ If presently employed, why do you wish to change? Have you ever been refused tenure (non-probationary) status? Yes No (If yes, comment below) Have you ever been discharged or requested to resign from a position? Yes No (If yes, comment below) Have you ever had a certificate or license revoked or suspended? Yes No (If yes, comment below) Have you ever taken the complete battery of National Teachers Examination? No Yes List other skills, licenses, fluency in other languages or certificates that are job-related: Employment Application Page 1 of 4 TEACHING EXPERIENCE In chronological sequence, list all teaching experience (do not include substitute teaching) Name of School School District City/County State Position Held: Grade or Subjects Month/Date /Year Total Years Supervisor s Name and Phone Number WORK EXPERIENCE OTHER THAN TEACHING List chronologically Employer City/County State Job Description Employment Dates Supervisor s Name and Phone Number

3 EDUCATIONAL AND PROFESSIONAL TRAINING List chronologically Level of Education Name of School State Field of Study Type of Degree Year of Graduation Dates of Attendance (from / to) College or University STUDENT TEACHING EXPERIENCE Name of School School District City/County State Grade Level and/or Subject Dates Employment Application Page 2 of 4 CERTIFICATION A. If you have been issued a Mississippi license, please submit a photocopy. Copy enclosed? Yes No License has not been issued Type of License Year of License Expiration Endorsement(s) B. If you do not currently hold a Mississippi license, have you made application? Yes No Does not apply Date Applied for license: C. If you have been issued a license or certificate in another state, please submit a photocopy. Yes No License has not been issued State Expiration Date License/Endorsements State Expiration Date License/Endorsements EXTRACURRICULAR ACTIVITIES Indicate the number of years experience in the activities listed below. Enter additional activities if necessary. Circle activities you are willing to coach sponsor. Extracurricular Activities Basketball College Contract Extracurricular Activities Intramural Director College Contract Volleyball Athletic Director Wrestling Athletic Trainer Volleyball Debate Track Forensics Cross-Country Drama Softball Yearbook Gymnastics Newspaper

4 Ice Hockey Football Golf Tennis Soccer Swimming Literary Magazine Student Government Honor Society Choir Cheerleading Dance SECURITY In which states have you lived the past seven years? (Include counties): Have you used any names (aliases, maiden names, married names, etc.) or Social Security numbers other than given on page one? Yes No If so, please list_ Have you ever been convicted of a felony or served time for a felony? Yes No Have you been convicted of any crimes of moral turpitude or offenses involving children, handicapped, or the elderly? Yes No Employment Application Page 3 of 4 If you answered yes to any of the previous questions, please describe below. Incident Date City and State Charge OTHER INFORMATION To avoid conflict of interest, list any local school board member or employee relative(s) in the school district and cite relationship. Estimate your to t al absence from w o rk or school f o r the last three years and e x plain th e reason( s ).

5 REFERENCES It is the applicant s responsibility to provide the following information in order to be considered for employment: Please list 3 references other than relatives, such as superintendent, principal, etc who have good knowledge of your character, personality, scholarship and teaching ability. Name of Reference Position / Relationship Mailing Address Phone Number CERTIFICATION AND RELEASE I certify that I have read and understand that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of act called for in this application may result in rejection of my application or discharge at any time during my employment. If employed, I agree to abide by all the policies approved by the Board of Trustees. I also understand that this application will remain in the active file for a period of one year and then will be classified as inactive unless I notify the personnel office to keep the application current. Applicants Signature Date Return this application to: Fudgie Parker Long Beach School District Commission Road Long Beach, MS Phone : Fax : The Long Beach School District will not discriminate on the basis of sex, race, color, religion, national origin, or disability in admission or access to, or treatment, or employment in its programs and activities to the extent provided by law. Any complaints of discrimination should be directed to : Kay Parker, Director of Human Resources, Long Beach School District, Commission Rd. Long Beach, MS 39560, Employment Applicati o n Page 4 of 4

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