/ County Line School District

Application for Certified Employment

Applicant Information

Full Name: /
Date:

Last

/

First

/

M.I.

Address:

Street Address

/

Apartment/Unit #

City

/

State

/

ZIP Code

Phone: /
Email

Cell Phone: ______

Are you a citizen of the United States? / YES / NO /
If no, are you authorized to work in the U.S.?
/ YES / NO
Have you ever been employed with County Line School District? / YES / NO /
If yes, when?
Have you ever been convicted of a felony? / YES / NO /
If yes, explain:
Are you currently on the child maltreatment registry? / YES / NO /
If yes, explain:
Have you ever been on an ALP? (Alternative Licensure Plan) / YES / NO /
If yes, explain:
Do you hold an Arkansas Teaching License? / YES / NO /
What type?
/ Standard £ Provisional £
Are you presently employed? / YES / NO /
Where and in what position?

Education

High School: /
Address:
From: /
To:
/
Did you graduate?
/ YES / NO /
Diploma:
College: /
Address:
From: /
To:
/

Did you graduate?

/ YES / NO /

Degree:

Student Teaching Location: ______Assignment: ______

On-Site Supervising Teachers: ______

College Supervising Teacher: ______

References

Please list three professional references.

Full Name: /

Relationship:

Company: /

Phone:

Address:
Full Name: /

Relationship:

Company: /

Phone:

Address:
Full Name: /

Relationship:

Company: /

Phone:

Address:

Previous Employment

Company: /

Phone:

Address:
Job Title: /

Supervisor: ______

Responsibilities:
From: /

To:

/

Reason for Leaving:

May we contact your previous supervisor for a reference? / YES / NO
Company: /

Phone:

Address:
Job Title:

Supervisor: ______

Responsibilities:
From: /

To:

/

Reason for Leaving:

May we contact your previous supervisor for a reference? / YES / NO
Company: /

Phone:

Address:
Job Title:

Supervisor: ______

Responsibilities:
From: /

To:

/

Reason for Leaving:

May we contact your previous supervisor for a reference? / YES / NO

Military Service

Branch: /

From:

/

To:

Rank at Discharge: /

Type of Discharge:

If other than honorable, explain:
Are you a present member of the National Guard? / YES / NO

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview could result in my release.

Signature: /

Date:

The County Line School District is an equal opportunity employer and shall not discriminate on the grounds of race, color, religion, national origin, sex, age, or disability