Clarksville Community Schools

Official Application Form for the position of Elementary Principal

Applicants are requested to:

• complete and submit this form by February 13

• attach a copy of their resume to this form if not previously submitted

• submit a copy of their credentials and transcripts

Mail all materials to:

Shellee Bartlett, Business Manager/Board Secretary

Clarksville Community Schools

318 N Mather

Clarksville, IA 50619-0689

PERSONAL INFORMATION

Name:______

Office Phone:______

Home Phone:______

Cell Phone: ______

e-mail address:______

Address:______City:______

State:______Zip Code:______

REFERENCES

Please list five current references who may be contacted—three professional and two community members (please include name, title, phone numbers and e-mail addresses where appropriate)

1. ______

2. ______

3. ______

4. ______

5. ______

CERTIFICATION

Do you currently hold a valid Iowa elementary principal’s endorsement? ____ Yes ____ No

If not, when would you expect to acquire?______

ADDITIONAL INFORMATION

If you answer “yes” to any of the following questions, please provide an explanation.

  1. Have you ever been convicted of a misdemeanor/felony other than a minor traffic violation?

____ No ____ Yes ______

  1. In connection with your professional responsibilities, have your ever been disciplined by a

court or licensing board of any state? ____No ____Yes

______

______

Note: Board will conduct a background check before issuing a contract to the successful applicant.

IOWA OPEN MEETINGS/RECORDS LAW

Because the position of Elementary Principal is one of public trust, the board and those acting for the board must be authorized to contact references (including persons not listed in formal application materials but who would know you and your work), investigate your background, and seek information deemed pertinent to determine qualifications of

candidates for this position.

Do you authorize the board and its agents to make such inquiries?

____ Yes ____Yes, only after notifying me of the intent to do so. ____ No

Iowa Code Chapter 21 requires a public record of meetings of the Board of Education.

Candidates being interviewed for this position will generally be interviewed in open session unless the candidate requests the interview to be in closed session.

Do you wish any Board interviews and deliberation regarding your professional competency concerns to be held in closed session?

____Yes (I believe any such discussion of perceived competency concerns may cause needless

and irreparable injury and I request a closed session.)

____No

The candidate may request that confidential application materials and their examination be kept confidential.

Do you wish to keep your application materials and their examination confidential and not subject to public view?

____Yes ____No

Please include any other materials that you believe support your application (e.g. articles authored by you).

I hereby certify that the information given in this application form and the attached vita is correct and true. I understand that, if employed, false statements herein shall be sufficient cause for dismissal.

Name______

Date ______