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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).

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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

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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?.....

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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 ( )

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For Office Use Only (do not write in this area)

____________Date Received Interview date set for______________ Certification verified_____

____________BCI/FBI Received (3) References received_______________

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