THE JAY SCHOOL CORPORATION
THE JAY SCHOOL CORPORATION
1976 W Tyson Rd - PO BOX 1239
PORTLAND, INDIANA 47371
(260) 726-9341 FAX (260) 726-4959
E-Mail jayschools.k12.in.us
PERSONNEL APPLICATION FOR CERTIFIED STAFF
Name: ______________________________________________________ Date: ____________
Present Address: ________________________________________________________________
Permanent Address (if different) ___________________________________________________
Present Telephone: __________________ Social Security # (optional): _________________
Parent / Spouse’s Name: _________________________________________________________
Are you under contract now? ________ Indiana Teacher Retirement Fund Number __________
Employer’s Name _________________________________ Earliest Date Available __________
Indicate Order of Preference
______ Elementary Teacher (K-5) __________________________________________
List Grade Levels in Order of Preference
______ Middle School Teacher (6-8) ________________________________________
List Grade/Subject Levels in Order of Preference
______ High School Teacher (9-12) ________________________________________
List Grade/Subjects in Order of Preference
______ Other (Please List) ________________________________________________
I. Education - High School and College Training Please include a copy of your high school/college transcripts
|Name Institution |Location |Date Attended |Date of Graduation |Degree |Major/Minor |
| | | | | |Credit Hours |
| | | | | | |
| | | | | | |
| | | | | | |
Recipient of the Indiana Work Ethic Certification ___ YES ___ NO (available after May 2006)
II. Experience Other Than Teaching (Include Military Service)
|Place |Occupation |Date Active |
| | | |
| | | |
| | | |
Student Teaching
|School Corporation |Dates |Subject/Grade |Supervising Teacher’s Name and Address |
| | | | |
| | | | |
| | | | |
Teaching Experience
|Name of School Corporation |Dates Employed |Subject/Grade Taught |Principal’s Name |Phone Number |
|and Location | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
V. License – Applicants must present a valid Indiana certificate or present evidence showing eligibility for an Indiana certificate. Special Education teachers should list areas of certification. Enclose a copy of your certification with this application
|Type/Kind of License |Grade |State |Expiration Date |Serial Number |Subject/Grade |
| | | | | | |
| | | | | | |
| | | | | | |
TOTAL YEARS OF PUBLIC TEACHING EXPERIENCE (not including student teaching) ______
TOTAL YEARS OF MILITARY SERVICE ______
VI. Do you have any relatives or close acquaintances employed by Jay School Corporation?
_____ Yes _____ No If “YES” list those persons: _________________________________
______________________________________________________________________________
VII. References – These should be individuals qualified to evaluate your personal and teaching qualifications. Please include administrators, supervisors, employers, critic teachers/college professors
|Name |Address |Position |Phone Number |
| | | | |
| | | | |
| | | | |
| | | | |
List your high school and college activities: _______________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
List any special abilities (musical, artistic, athletic, debate, etc.) ________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
List your professional, honorary, and service organization memberships: ________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
VIII. Additional Information – Add any other employment, training, or autobiographical information
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
IX. Could you come to Jay Schools for an interview? ____________
X. Please have your college credentials available
XI. Re-submit letter of interest each school year or notify us annually that you wish to keep this file active.
XII. Request for Background Information
Positions with Jay School Corporation involve contact with our student population. Complete questions below to help us evaluate your suitability to work with students. All applicants for employment are expected to provide us with background information; you are not being singled out from other applicants for closer inspection. These questions are a part of the application and any misrepresentation or omission of facts may be grounds for disqualification from further consideration or for termination from employment regardless of when the misrepresentation or omission is discovered.
Conviction of a crime or any affirmative answer provided by you is not an automatic bar to employment. The Jay School Corporation will consider the nature of any conviction or alleged conduct underlying an affirmative response, the date of the alleged conduct in question, your intervening conduct, the relationship between an offense or alleged conduct underlying an affirmative response, and the position for which you are applying. If you answered yes to any of the following questions, please explain the circumstances of each on a separate sheet of paper and attach that paper to this application.
1. If you are now working, is your conduct as an employee or the quality of your work the focus of any investigation by your current employer? _____ yes _____ no
2. Have you ever resigned from a job after being disciplined by your employer or after being offered the opportunity to resign rather than be terminated? _____ yes _____ no
3. Have you ever been investigated for, charged with, or plead guilty or "no contest 'to any crime involving the sexual abuse of any person or indecency with a minor? _____ yes _____ no
4. Have you ever been convicted of or plead guilty to a crime, offense or infraction (including traffic infractions or offenses), other than those described in 3 above, that have not been expunged by a court or placed under seal? ______yes ______no
5. Have you ever been charged with a crime, where the court has deferred further proceedings without entering a finding of guilt? ______ yes ______no
XIII. Authorization and Release
I authorize the administration of The Jay School Corporation to check my employment history, including without limitation, reference checks. Additionally, I waive in connection with any request for, or provision of such information, any claims, causes or actions, including without limitation, defamation, infliction or emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the school corporation, its officials, employees, trustees, or agents, or against any provider of such information. I have read this authorization and release of all claims, and I expressly agree to the terms set out herein.
I understand that if employed: 1) any misrepresentation or omission of facts requested in the application is cause for dismissal and 2) If employment is for no definite period that I may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.
XIV. Agreement
I certify that the information given on this application is true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries as may be necessary in arriving at an employment decision. I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of the Jay School Corporation.
_____________________________________ ____________________
Signature of Applicant Date
Jay School Corporation will not discriminate on the basis of race, color, religion, sex, national origin, age, or handicapping conditions, including limited English proficiency, in its educational programs or employment policies as required by state and federal law. Revised 9/2013
The Jay School Corporation
1976 W Tyson Rd ● P O Box 1239 ● Portland, Indiana 47371
Phone (260) 726-9341 ● Fax (260) 726-4959
jayschools.k12.in.us
Police Record Release Form
Applicant to Complete
We request the following record check on:
(please print)
Name:__________________________________________________________________
First Middle Maiden Last
Date of Birth ________________________ Social Security # _____________________
Address ________________________________ Phone # ________________________
Home
_________________________________ Phone # _________________________
Cell
_________________________________
I hereby submit this written authorization to release to The Jay School Corporation any police and/or court records including convictions which directly or indirectly involve me, except those involving a crime that has been expunged by a court or placed under seal. I agree to let the above see and have copies of these records if so desired (by paying any required copying fees). I hereby release your employees and the Police/Sheriff Department from any and all liabilities for any damages whatsoever which might result from furnishing the JSC with such records.
Signature: _________________________________
To be completed by Local Police Department:
I certify that a police record check was made on the person listed above at the
_______________________County Sheriff Department and
__________ No record was found to exist.
__________ A record exists and copies are following.
Name of verifying official _______________________ Title _____________________
Signature of verifying official ____________________ Date_____________________
Revised: 9/2016
Jay
Jeremy Gulley, Superintendent Brad DeRome, Business Manager/Treasurer
Trent Paxson, Ed.S., Director of Curriculum & Instruction Ann Van Horn, Special Education Director
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