ST. PIUS X / ST. LEO SCHOOL
6905 Blondo Street
Omaha, Nebraska 68104
Phone (402) 551-6667
APPLICATION FORM and QUESTIONNAIRE - TEACHER
Name
(last) (first) (middle)
Permanent address Permanent phone
(city) (state) (zip)
Present address (if different) Present phone
(city) (state) (zip)
Birth: E-Mail address
(month) (day) (year) (optional)
Religion Parish
If Catholic, and married, what is the name of the church in which you were married?
City and State Priest
Do you have any problems with the fundamental teachings and beliefs of the Catholic Church?
Yes No If yes, what:
Do you hold a valid Teaching Certificate? Yes No
If Yes: State Type Rank
Level Valid Period
Which grade do you prefer: first choice second choice
Which subject area do you prefer: first choice second choice
Areas of Specialization
If No: Will you be able to secure a NE certificate prior to beginning employment?
Yes No
Are you presently under contract? Yes No
If yes, can you secure a release? Yes No
If you are presently employed, may we contact your present employer to check your work record? Yes No
Are you authorized to work in the United States? Yes No
Can you perform the essential functions of the position for which you are applying, with or without reasonable accommodation? Yes No
Have you applied for employment here before? Yes No
When?
Have you ever been employed by the Archdiocese, any Catholic parish or school, or other Catholic agency? Yes No
Where and when?
Has your employment or volunteer service ever been terminated by any parish, school, agency, or organization? Yes No
If yes, please explain on additional sheets.
Have you ever been convicted of a crime (including driving while impaired or its equivalent, but excluding minor motor vehicle offenses)? (Please note that an affirmative answer does not automatically disqualify you from being considered as a candidate for employment). Yes No
If yes, please explain on additional sheets.
EMPLOYMENT
PRESENT AND ALL PRIOR DATES INDICATE FULL-
EMPLOYERS (Including address EMPLOYED TIME OR PART- REASON
& telephone number) POSITION From To TIME (If part-time FOR
LIST MOST RECENT FIRST HELD Mo/Yr Mo/Yr # of hrs /wk) LEAVING
Practice Teaching:
School Supervisor
Location
Dates Grade(s)
School Supervisor
Location
Dates Grade(s)
EDUCATION
Name and Location of School Diploma/Degree Con- Semester Hours
(Include College, Graduate Dates ferred (Please indicate Credit Beyond
Work, and Summer Sessions) Attended Major and Minor) Degree
HIGH SCHOOL:
UNDERGRADUATE:
GRADUATE:
VOLUNTEER EXPERIENCE
Please list your volunteer experiences with churches, schools, civic, or non-profit organizations (use back if needed).
Telephone
Organization Position Dates Contact & Address
REFERENCES
List three people, unrelated to you, one of whom must be a recent employer, who can attest to your qualifications for this position.
Home Work
Telephone Telephone
Name Address Number Number Occupation
OTHER QUALIFICATIONS
In addition to your work history, what other experiences, skills, or qualifications would enhance your candidacy for this position?
BACKGROUND CHECK
If the position for which you are applying requires that you regularly work with individuals under the age of 19 or if you are applying for a position with the Archdiocesan Administration, you must undergo a background check. Please complete the attached Authorization form. If you are a non-citizen of the United States, please attach to this form a copy of your registered alien card or other proof that you are legally residing in the United States.
**** Please have your confidential file sent to St. Pius X / St. Leo School if you have one. If not, please send any letters of recommendation you might have.
**** Please attach to this application a written summary of your reasons for wanting to teach in a Catholic school.
I certify that I have made true, correct, and complete answers and statements on this application in the knowledge that they may be relied upon in considering my application, and I understand that any omission, false answered statements made by me on this application or any supplement to it will be sufficient grounds for failure to employ or for my discharge should I become employed with the school.
Signature Date
St. Pius X / St. Leo School is an equal opportunity affirmative action employer and does not unlawfully discriminate on the basis of race, national origin, color, sex or age. It is our intention that all applicants be given equal opportunity and that selection decisions are based on job-related factors.
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