Unified School District of De Pere

1700 Chicago Street

De Pere, WI 54115

Telephone: (920) 337-1032

Position Applied For / Date
Name:
Last / First / MI / Former / Social Security Number
Present Address:
No. / Street / City / State Zip
Telephone / Cell Phone / Email
Are you under contract? ___No ___Yes Expiration Date: _____/______/______
Date of Availability / Have you filed an application with the De Pere School District previously? ___No ___Yes
If yes, when ___/___/_____ Under what name: ______
Current Salary
Check the level you are certified in and for which you will accept an assignment. List in preference order, under the respective level, the grades, subjects, or special areas for which you are applying.
ð Elementary (Grades K-5) / ð Middle School (Grades 6-8) / ð High School (Grades 9-12)
A) / A) / A)
B) / B) / B)
C) / C) / C)

Academic Preparation

Name of Institution / Degree Granted / GPA / Major
High School
College/University
College/University
College/University

Do you hold a valid Wisconsin teaching license or certificate? _____No _____Yes

Type of License (be specific)______Exp. Date:____/_____/_____

Do you hold a teaching license or certificate from a state other than Wisconsin? _____No _____Yes

If yes, Type of License (be specific)______Exp. Date:____/_____/_____

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Professional Experience:

From
Mo/Yr / To
Mo/Yr / School / Address / Zip / Phone / Grade or
Subject / Supervisor

Have you ever been dismissed or asked to resign from any position? _____No _____ Yes - If yes, please explain and attach further explanation as necessary.

Non-Teaching Experience (include military service):

From / To
Mo/Yr. / Mo/Yr. / Organization / Address / Zip / Telephone / Supervisor

Have you ever been dismissed or asked to resign from any position? _____No _____ Yes - If yes, please explain and attach further explanation as necessary.

The Board of Education prohibits discrimination against any employee or applicant based on his/her disability. As such, this School District will not engage in employment practices or policies that discriminate on the basis of disability against qualified individuals with disabilities in every aspect of employment, including recruitment, hiring, promotion, demotion, layoff and return from layoff, compensation, job assignments, job classifications, paid or unpaid leave, fringe benefits, training, and employer-sponsored activities, including recreational and social programs. In addition the Board will provide qualified applicants and employees with known disabilities with reasonable accommodations that do not impose undue hardship. Information on how accommodations will be provided and how they can be requested is available on the District website (www.depere.k12.wi.us) under the Employment link and/or can be obtained by request in the District Business Office at 1700 Chicago Street.

PROFESSIONAL APP NOV 2010 Page 1

u Have you ever been found guilty of any violations of law or do you presently have charges pending relating to any violations of law (felonies and/or misdemeanors) other than minor traffic violations? (In accordance with State law pending charges or convictions will not be considered unless substantially related to circumstances of the particular job.)

_____No _____Yes - If yes, please attach a complete written explanation.

u Freedom from non-prescribed controlled substances is a condition of employment in the Unified School District of De Pere. Are you free from non-prescribed controlled substances? _____No _____Yes

u Explain any additional experiences, talents, skills or extracurricular contributions that you possess which would be applicable to the position for which you are applying.

u I authorize the Unified School District of De Pere (USDDP), in De Pere, Wisconsin, to make any inquiry of or receive any information from any person or organization regarding my suitability for employment, and do hereby expressly give permission to these persons or organizations to provide such information. Such inquires may include, but are not limited to, the verification of any information set forth in this application, the quality and quantity of my work, my work history and medical records, and my character, qualifications, and background. In consideration for the cooperation extended to USDDP by release of such information, I forever waive, release, and covenant not to sue any person or organization, including USDDP and its agents and employees, for providing, obtaining, verifying, or otherwise acting upon such information. I give this waiver, release, and covenant not to sue for myself, my heirs, assigns and successors in interest forever. I do so understanding that the information obtained may be such as to disqualify me for employment, result in rejection of my application, or my dismissal from employment. I understand that such information is sought with confidentiality, and I will not request copies thereof. I certify that all information provided herein is accurate to the best of my knowledge, information and belief, and I acknowledge that any false statements, incomplete statements, or misrepresentations may subject me to disqualification, rejection, or dismissal at any time. A copy of this authorization shall be as effective as the original for the purposes stated above. I have read and understand the foregoing certification, and sign below voluntarily and with knowledge of its contents.

Signature Date

The Board of Education does not discriminate on the basis of any characteristic protected under State or Federal law including, but not limited to race, color, age, sex, creed or religion, genetic information, handicap or disability, marital status, citizenship status, veteran status, military service, sexual orientation, national origin, ancestry, arrest record, conviction record, use or non-use of lawful products off the District’s premises during non-working hours, or any other characteristic protected by law in its employment practices. Any person that believes that s/he has been discriminated against or denied equal opportunity or access to programs or services may file a complaint, with one of the District’s Civil Rights Coordinators, or the District Administrator. Any person that believes that s/he has been discriminated against or denied services may file a complaint, with one of the District’s Civil Rights Coordinators, or the District Administrator. Complaint Coordinators: Robert Lennon, Director of Pupil Services, or Marcy Becker, High School Guidance Counselor at De Pere Public Schools, 1700 Chicago Street, De Pere, WI 54115; Telephone: 920-337-1032; Email or .

PROFESSIONAL APP NOV 2010 Page 1