To: - Ohio School Boards
Licking County ESC
SUPERINTENDENT’S OFFICE
675 Price Road, Newark, Ohio 43055
TELEPHONE (740)-349-6089
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APPLICATION FOR SUPERINTENDENT
FAIRFIELD COUNTY ESC
Please type or print in black ink
_________________________________________________________________________
Last Name First Name Middle Date of Application
_________________________________________________________________________
Street Address Social Security No.
_________________________________________________________________________
City State Zip Code Telephone No.
Home: __________
Work: __________
___________________________
e-mail address
Present Position: ____________________ Present Employer: _______________________
Are you presently under contract to another district? Yes____ No_____
If yes, when does the contract expire? ___________________
Date available for employment? _________________________
Do we have permission to contact your present employer?___________
Current base salary?
(Not including fringe benefits) __________________________________________
Do you hold a valid Ohio Superintendent’s License?______________ Expiration Date?________ License No.
Have you ever been convicted of a felony? Yes____ No_____ If yes, please explain.
(Please fill out this application carefully as information given herein becomes a legal part
of the contract in case of selection. Do not omit any item, unless it is stated to be omitted).
page 1
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References:
Name Address Telephone
1.__________________________________________________________________________
2.__________________________________________________________________________
3.__________________________________________________________________________
4.__________________________________________________________________________
5.__________________________________________________________________________
6.__________________________________________________________________________
Do we have permission to contact the above named persons?________
State the competencies, skills and strengths which you consider qualify you for this position:
Enter the work experiences you have had starting with most recent:
Place Job Title Years (from to) Reason left position
_____________ ___________ ______________ _________________________
_____________ ___________ ______________ _________________________
_____________ ___________ ______________ _________________________
_____________ ___________ ______________ _________________________
_____________ ___________ ______________ _________________________
_____________ ___________ ______________ _________________________
The Fairfield County ESC, by adopted policy, does not discriminate against applicants
on the basis of race, religion, sex, ancestry, national origin, color, or disability .
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[pic]Certificates which you presently hold :
Certificate # Expiration date Type Grade Class Status
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
If not holding the certificate needed for this position, do you have verification of
obtaining one?
1. List Professional activities and or memberships:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Have you ever been convicted of a felony? ___Yes ___No If yes please explain....
__________________________________________________________________________
__________________________________________________________________________
3. Are you currently under contract? ___Yes ___No With whom?______________________
4. Have you ever been issued continuing status as a teacher? ___ No ___ Yes
Where?____________________________________________________________________
5. Why do you wish to make a change? __________________________________________
__________________________________________________________________________
6. What is your present salary? $___________ What salary do you expect for this
position? $______________
7. When could you come for a personal interview?_______________ Time__________
All prospective employees will be subject to a B.C.I. /F.B.I. (Bureau of Criminal Investigation)
check at their own expense. Employment shall be CONTINGENT on an acceptable B.C.I./F.B.I. reports
page 3
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************************(Answer here in your own handwriting.....)********************
8. Why do you want to work for the Fairfield County ESC?.....
9. What responsibilities or experiences have you had with special education?
10. Write a brief statement as to whether you are a manager or a leader and why you think that is important....
11. How would you use student and staff data to improve understanding by administration and
Board members on a monthly basis?.....
***********************************************************************************************
Be sure to have on file no later than February 28, 2011 the following items:
1. Transcripts and / or College Placement Packet
2. Copy of Current Superintendent Certificate/License
3. Have three (3) References by someone professional who has known you at least a year (not relatives)
4. Current Resume and letter of Application
5. Completed Application
"I hereby certify that the answers on this application are true and correct to the best of my knowledge and belief and that any deliberate misrepresentation of fact contained herein may be grounds for invalidating my contract commitments resulting from this application. I understand that my employment will be subject to the laws of the State of Ohio and to the job descriptions and policies adopted by the Fairfield Co ESC Board of Education."
_______________________________ ___________________________________________
Date Signature
AN EQUAL OPPORTUNITY EMPLOYER
Return to: Licking County Educational Service Center
Supt. Nelson McCray
675 Price Road
Newark, Ohio 43055 ( )
*******************************************************************************
For Office Use Only (do not write in this area)
____________Date Received Interview date set for______________ Certification verified_____
____________BCI/FBI Received (3) References received_______________
page 4
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