Orion Community Unit School District 223

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1 Orion Community Unit School District 223 ORION, ILLINOIS Application Date: Position Applying for: Name: Social Security # U.S. Citizen? Are you legally eligible to work in the United States? Home Phone: Cell Phone: Current : Permanent Post-Secondary Education: College Location GPA Degree (Major & Minor) Dates Attended/ Graduated Please note any additional graduate hours that have been completed regardless if a degree was attained. High School Attended: Location: Do you hold an Illinois Teaching Certificate? If not, have you applied for this certificate? Do you hold a teaching certificate from another state? If so, which state(s): What certifications, endorsements or approvals have you achieved?

2 Prior Employment: (begin with current/most recent) Employer 1 Dates of experience _ / _ / to / _ / Position: Employer 2 Dates of experience _ /_ / to / _ / Position: Employer 3 Dates of experience / / to / / Position: Employer 4 Dates of experience / / to / / Position:

3 Military: Active Duty: / / to / / Reserve Duty: Branch: Location of Duty: Rank at Discharge: Branch: Obligation Period: Times of Current Training Duty: Type of Discharge: References: List at least three who have evaluated your teaching skills and abilities. Name Employer & Position Phone: Work & Home

4 Candidate Questions: Each candidate is required to provide in the space below, any additional information that will assist the district in evaluating the candidate s qualifications. Please type your answers to the following questions limiting your responses to 100 words per question. 1. Why are you interested in this position? 2. What personal or professional qualities set you apart from other candidates? 3. What do you think is the most important component of a lesson plan? Explain your answer. 4. What influenced your decision to become an educator?

5 Have you previously held a licensed position in an Illinois public school district? If yes, have you successfully completed a four-year 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. The date of the offense and the relationship between the offense and the position for which you are applying will be considered. Are you able to perform, with or without reasonable accommodation, the essential job functions required of this position? If no, 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 of this information. I authorize all current and former employers to release any information concerning my background. I also understand that this document is not to be made available for public discussion, and that all board deliberations related to this position will be held in closed session. Signature Date

6 Orion Community Unit School District 223 Licensure Statement: Has your license to teach ever been revoked or suspended or have you ever been otherwise disciplined, in any way, by any licensing department, agency or entity? If your answer is yes, please explain on a separate sheet. Yes No I agree to immediately notify the school district if I should be convicted of a felony, or any crime involving dishonesty, mistreatment of a minor, or a breach of trust while my application in pending, or during my period of employment, if hired. day of, Legal Signature of Applicant Orion Community Unit School District 223 is an Equal Opportunity Employer and in accordance with Federal and Illinois law does not discriminate on the basis of race, color, national origin, citizenship status, religion, sex, marital status, age, disability, disabled veteran status, or arrest record. A fingerprint-based criminal history records check and a check of the Statewide Sex Offender Database are required for employment. Failure to consent to fingerprinting or the background check will make the person ineligible for employment with the District. Each newly hired employee must complete an Immigration and Naturalization Service Form as required by Federal Law. The District retains the right to discharge any employee whose criminal background investigation reveals a conviction for committing or attempting to commit any of the offenses outlined in Paragraph of The School Code or who falsifies, or omits facts from, his or her employment application or other employment documents.