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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