APPLICATION FOR EMPLOYMENT

CLASSIFIED POSITION

CASEY COUNTY BOARD OF EDUCATION

1922 N. US 127

LIBERTY, KY 42539

The Casey County Board of Education does not discriminate in employment practices on the basis of sex, race, color, creed, national origin, disability or age.

DATE: ______

NAME: ______

Last First Middle/Maiden

ADDRESS: ______

Street City State & Zip Code

TELEPHONE: ______

SS#: ______DATE OF BIRTH: ______

POSITION DESIRED (Please circle all that apply):

AIDE COOK JANITOR SECRETARY SUBSTITUTE

POSITION COMMENTS: ______

PREVIOUS WORK EXPERIENCE:

DATES OF EMPLOYMENT
OR # OF YRS. /

EMPLOYER

& EMPLOYER ADDRESS OR PHONE NUMBER

/

POSITION

HELD

Do you have a High School Diploma or a High School Equivalence Certificate? Yes ______No ______

REFERENCES: (Please list individuals who can testify to the quality of your work and/or character.)

NAME

/

ADDRESS

/

POSITION

LIST BELOW ANY ADDITIONAL INFORMATION RELATIVE TO THIS APPLICATION FOR EMPLOYMENT:

______

______

______

______

______

ANTI-NEPOTISM STATEMENT:

Are you related to the Superintendent or any member of the Board of Education in any of the following areas? (Check ONLY the relationship(s) that apply)

Father ______Mother ______Brother ______Sister ______

Husband ______Wife ______Son ______Daughter _____

Aunt ______Uncle ______Son-in-law ______Daughter-in-law ______

FOR THIS TYPE OF EMPLOYMENT, STATE LAW REQUIRES A STATE CRIMINAL HISTORY BACKGROUND CHECK AS A CONDITION OF EMPLOYMENT. UNDER CERTAIN CIRCUMSTANCES, A NATIONAL CRIMINAL HISTORY BACKGROUND CHECK MAY BE REQUIRED AS A CONDITION OF EMPLOYMENT.

I HEREBY AFFIRM THAT THE INFORMATION ON THIS FORM IS ACCURATE AND CORRECT:

______

Signature Date

APPLICATION FOR EMPLOYMENT

CERTIFIED POSITION

CASEY COUNTY BOARD OF EDUCATION

1922 N. US 127

LIBERTY, KY 42539

The Casey County Board of Education does not discriminate in employment practices on the basis of sex, race, color, creed, national origin, disability or age.

DATE: ______POSITION APPLIED FOR: ______

I. PERSONAL DATA

NAME: ______

Last First Middle/Maiden

ADDRESS: ______

Street City State & Zip

TELEPHONE: ______SS#:______DATE OF BIRTH:______

II. PROFESSIONAL PREFERENCES

PLEASE LIST BELOW, IN ORDER OF PREFERENCE, SPECIFIC POSITIONS, GRADE LEVELS OR SUBJECTS FOR WHICH YOU WISH TO BE CONSIDERED:

1. ______2. ______3. ______

IF EMPLOYED, WHEN ARE YOU ABLE TO BEGIN WORK? ______

III. EDUCATION & PROFESSIONAL PREPARATION:

Name of School

/ Address of School / Degree /

Date Received

/ Major/Minor

*NOTE: Indicate date degree may be expected if application is filed prior to completion. A current copy of a transcript of college credits is required.

STUDENT TEACHING EXPERIENCE:

Dates:
From: To: / Name & Address of School / Grade or Subject / Supervising Teacher / Grade Received

HAVE YOU TAKEN THE NATIONAL TEACHER’S EXAMINATION? _____ YES _____ NO DATE: ______

(If yes, please submit a copy of the scores.)

IV. CERTIFICATION (Please submit a copy of your certificate or statement of eligibility.)

DO YOU HAVE A VALID KENTUCKY CERTIFICATE? _____ YES _____ NO EXPIRATION DATE: ______

TITLE OF CERTIFICATE: ______RANK : ______

V. PROFESSIONAL EMPLOYMENT EXPERIENCE IN EDUCATION

HAVE YOU BEEN PLACED ON CONTINUING CONTRACT PREVIOUSLY? _____ YES _____ NO

IF YES,

WHEN: ______WHERE: ______

HAVE YOU BEEN EMPLOYED IN THIS DISTRICT PREVIOUSLY? _____ YES _____ NO

IF YES,

WHEN: ______IN WHAT CAPACITY: ______

HAVE YOU ACCUMULATED ANY KENTUCKY SICK LEAVE? _____ YES _____ NO

IF YES,

HOW MANY DAYS: ______WHERE: ______

HAVE YOU EVER FAILED TO HAVE A CONTRACT RENEWED? _____ YES _____ NO

BEEN DISMISSED FROM EMPLOYMENT IN A SCHOOL SYSTEM? _____ YES _____ NO

RECEIVED AN ANNUAL UNSATISFACTORY EVALUATION? _____ YES _____ NO

TEACHING/ADMINISTRATIVE EXPERIENCE:

Name & Address of School / Position or Subject/ Grades Taught / Dates:
From: To: / Reason for Leaving
VI: OTHER WORK EXPERIENCE

Type of Work

/

Name & Address of Employer

/

Dates:

From: To:
VII: REFERENCES

Name

/ Official Position / Address & Telephone

VIII: ANTI-NEPOTISM STATEMENT:

Are you related to the Superintendent or any member of the Board of Education in any of the following areas? (Check ONLY the relationship(s) that apply)

Father ______Mother ______Brother ______Sister ______

Husband ______Wife ______Son ______Daughter _____

Aunt ______Uncle ______Son-in-law ______Daughter-in-law ______

I HEREBY AFFIRM THAT THE INFORMATION ON THIS FORM IS ACCURATE AND CORRECT.

______

Signature Date