Date:



Date: ____________

Southgate Independent School

William Blatt and Evergreen Avenue

Southgate, Ky. 41071

Phone(859)-441-0743 Fax(859)-441-6735

CERTIFIED POSITION APPLICATION

Information and Application Form

Name: ___________________________________________________

(Last) (First) (MI)

Telephone Number: ______________ S.S. Number: _________________

Present Address: _______________________________________________

(Street) (City) (Zip)

Telephone Number: _____________Email__________________________

Type of Position Desired: ________________________________________

Type of Certificate Held: ________________________________________

Certificate Effective Date: _____________ Expiration Date: ____________

Certificate Code: _______________ Grade Ranges: ___________________

*Educational and Professional Training

| |School or Institution |Degree or Number of Credits | | |

|High School | | | | |

|College | | | | |

|College | | | | |

|College | | | | |

|College | | | | |

|Graduate School | | | | |

*Professional Experience

|Name of School |Location |Grade or Subjects |Dates |Name of Immediate |

| | | | |Supervisor |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

TOTAL EXPERIENCE _____ YEARS

Are you presently under contract? _____ If yes, where? _______________

Have you ever been employed under a continuing contract as an educator in Kentucky? Yes _____ No_____ If yes, when and where?

_____________________________________________________________

Have you ever had a limited contract for teaching non-renewed by another school district? Yes_____ No_____ If yes, when, where, and why?

_______________________________________________________________________________________________________________________________________________________________________________________

*Other Work Experience

|Employer |Mailing Address |Position |Dates |

| | | | |

| | | | |

| | | | |

Please describe any extra activities you are able and willing to direct or supervise.

References

(Give three references, including supervisors that you have worked for)

|Name |Phone Number |Position |

| | | |

| | | |

| | | |

Have you ever been convicted of a crime? (Other than minor traffic violations) Yes ____ No____ If yes, attach explanation.

Applicant’s Authorization for Release of Information

(Read carefully before signing)

All information provided by me in support of my application for employment is true and correct to the best of my knowledge. I understand that misrepresentations or omissions may be cause for rejection or may be cause for subsequent dismissal if I am hired.

I authorize this district to conduct a background investigation and authorize the release of information in connection with my application for employment. This investigation may include such information as criminal or civil convictions, previous employers and educational institutions, personal references, professional references, and other appropriate sources. I waive my right to access to such information and without limitation hereby release this district and the reference source from any liability in connection with its release or use.

FOR THIS TYPE OF EMPLOYMENT, STATE LAW REQUIRES A NATIONAL AND STATE CRIMINAL HISTORY BACKGROUND CHECK AS A CONDITION OF EMPLOYMENT. THIS DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER ON THIS APPLICATION IS MANDATORY PURSUANT TO KENTUCKY REVISED STATUTE 160.380 AND KENTUCKY STATE POLICE REQUIREMENTS. YOUR SOCIAL SECURITY NUMBER WILL BE USED FOR PURPOSES OF CRIMINAL BACKGROUND CHECKS AND ANY OTHER PURPOSES OF CRIMINAL BACKGROUND CHECKS AND ANY OTHER PURPOSE REQUIRED BY FEDERAL LAW.

____________________ _____________________________

Date Signature

The Southgate Independent School District provides equal employment opportunities to all people without regard to race, color, age, national origin, gender, religion or disability.

*PLEASE ATTACH ADDITIONAL PAGES AS NEEDED.

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