APPLICATION FOR POSITION & SECURITY SCREENING

Requesting Party\Date: North Park Elementary School

Reason for Background Check: Work in School

APPLICANT INFORMATION

Please Print Clearly and Fill in All Information

Position you are applying for:

Last Name First Name Indicate Jr/Sr. Etc.

List all other names used including Maiden:

Date Used:

Date Used

Current Address

City State Zip

Home Phone Number ______

E-Mail address

Date of Birth Driver License Number State

State Identification Number

Professional License Number

State Issued Type of License

EMPLOYMENT

List All Employment for the Past Ten Years Starting with Most Current

Name of Employer

If Placed by an Agency, Name of Agency

Employer’s Address/City/State

Name of Supervisor Dates To

Reference Name and Phone ( )

Job Title

Reason for Leaving

Name of Employer

If Placed by an Agency, Name of Agency

Employer’s Address/City/State

Name of Supervisor Dates To

Reference Name and Phone ( )

Job Title

Reason for Leaving

Name of Employer

If Placed by an Agency, Name of Agency

Employer’s Address/City/State

Name of Supervisor Dates To

Reference Name and Phone ( )

Job Title

Reason for Leaving

Name of Employer

If Placed by an Agency, Name of Agency

Employer’s Address/City/State

Name of Supervisor Dates To

Reference Name and Phone ( )

Job Title

Reason for Leaving

Experience working in education:

Talents, interests, or hobbies which might be useful:

List all Cities, States, and Dates where you have lived for the past ten years:

City State Dates From To

EDUCATION

Name of High School

City State Last date attended

List all Colleges or Universities you attended:

Name of School City/State Dates Left

List Degrees/Diplomas/Certificates

Graduation Date

What is the highest degree you have earned?

Certification Type

I authorize the school to conduct reference checks with my former employers. I further certify that all statements in this application are true.

Signature Date

Please answer the following using additional paper if necessary.

1)  Expand on experience and training in your preferred grade.

2)  What do you feel should be the role of parents in educational decision-making?

3) Why do you want to teach in a private elementary school?

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