PROFESSIONAL EMPLOYMENT APPLICATION (Certified Personnel Only)

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2 LOUISVILLE MUNICIPAL SCHOOL DISTRICT P.O. Box 909 Louisville, MS voice: fax: PROFESSIONAL EMPLOYMENT APPLICATION (Certified Personnel Only) The Louisville Municipal School District does not discriminate on the basis of sex, race, color, handicap, religion, or national origin and is in compliance with Title IX directives in its educational programs, activities, and employment policies. This completed application along with official transcripts from colleges and/or universities must be submitted to the Office of the Superintendent before an applicant will be considered for employment. Application forms are sent to all who request them regardless of existing vacancies. NAME: LAST FIRST MIDDLE PRESENT ADDRESS: Street/Route-Box City/State/Zip PERMANENT ADDRESS: TELEPHONE: Present Permanent ADDRESS: SOCIAL SECURITY NUMBER: - - POSITION FOR WHICH APPLYING (CHECK ONE OR MORE) Administrator Position(s) Preferred: Band Director Grade Level Preferred: Coach of Athletics Area(s) Preferred: Elementary Teacher Grade Level Preferred: Guidance Counselor Elementary Secondary Vocational Librarian Secondary Teacher Subject(s) Preferred: Special Education Grade Level Preferred: Supervisor Subject/Grade Level: MISSISSIPPI TEACHING CERTIFICATE(S): CLASS TYPE ENDORSEMENT AREA(S) EXPIRATION DATE

3 PREPARATION FOR TEACHING Beginning with high school, list all colleges, universities, business schools, technical schools, service schools, and other training schools attended in preparation for teaching. Institution and Dates Major Hours Degree Address From - To Field Earned Awarded TEACHING EXPERIENCE Beginning with Student Teaching, list all prior teaching experience. School and Dates Address From - To Grade Subject Number of Years OTHER WORK EXPERIENCE Employer and Address Dates From - To Assignment

4 REFERENCES List five (5) references. Include three (3) professors, supervising teachers, principals, or superintendents who would have first hand knowledge of your teaching abilities and skills. Please do not use relatives as references. Phone Name Position Complete Address Number ADDITIONAL INFORMATION Estimate the number of days you have been absent from work or college in the past three (3) years due to illness or injury. Are you presently under contract with another school district? If yes, explain. List co-curricular/student groups which you are prepared to advise, coordinate, and or direct. List institutes, clinics, and/or workshops attended during the past (5) years. Title Place Date Are you currently enrolled in a graduate program leading to a degree? If so, in what field? Where? When will you be available for an interview?

5 IN YOUR OWN HANDWRITING, (1) tell why you wish to be employed by the Louisville Municipal School District and (2) provide a statement regarding your personal and professional background including pertinent information not included elsewhere in this application. By my signature, I attest that the information contained in this application is true and represents me accurately and that the school district is authorized to investigate my personal history and employment record including my present employer to secure pertinent information for my file for a period of one (1) year from the date it is received and then will be classified as inactive unless I notify the school district in writing to keep this application current. While in the employ of the Louisville Municipal School District, I agree and obligate myself to perform such duties as required by law and such additional duties as may be prescribed under duly adopted policies, rules, and regulations of the Board of Trustees of the Louisville Municipal School District. signature of applicant date LMSD-05/91R DATE RECEIVED BY LMSD: AN EQUAL OPPORTUNITY EMPLOYER

6 LOUISVILLE MUNICIPAL SCHOOL DISTRICT 112 South Columbus Avenue P. O. Box 909 Louisville, MS (662) Authorization for Background Check I authorize the Louisville Municipal School District to conduct a background screening check with law enforcement agencies, the Child Abuse Central Registry, previous employers, and any other person or organization to determine my suitability for employment. I hereby release from liability the Louisville Municipal School District and its representatives for seeking such information, and all other persons, corporations, or organizations for furnishing such information. I further understand this authorization is a part of my application for a position with the Louisville Municipal School District. I UNDERSTAND MY EMPLOYMENT IS CONTINGENT UPON THE INFORMATION OBTAINED IN A BACKGROUND CHECK, AND MY CONTRACT OR AT-WILL AGREEMENT IS VOIDABLE BASED ON THIS INFORMATION. Date: Signature: Name: (Please print) First Middle Last Maiden Address: Social Security Number: Phone Number:_( ) Date of Birth: A fee of $32.00 will be charged at the time of the background check. Must be paid by certified check, money order, or cash (correct amount). Do not send payment with application. Fingerprinting Hours: Tuesdays 9:00 A. M. 10:00 A. M. Louisville Public School s Central Office, 112 South Columbus Avenue, Louisville, MS For Office Use Only PAID BY: ( ) Check ( ) Cash ( ) Other DATE PAID: MONEY COLLECTED BY: