Hill CitySchoolDistrict51-2

Date:

Hill City SchoolDistrict

POBox659

Hill City,SD57745

Phone:(605)574-3030

Fax:(605)574-3031

Name:

CurrentAddress:

City,StateZip:

PermanentAddress:

City,StateZip:

HomePhone:

CellPhone:

E-Mail:

CertifiedEmployeeApplication

Applicantsarerequestedtofillthisformoutin itsentirety.Aformalletterofapplication, completeresume,andteachercredentialsare alsorequiredaspartoftheapplication process.Pleasehaveyourplacementoffice forwardyourcredentialfiletotheattentionof Mike Hansonattheaddresslistedaboveas soonaspossible.

CurrentSouthDakotaCredentials

CertificateNumber:

CertificateExpiration:

CertifiedAreas:

ProfessionalEducation:

PositionsAppliedfor:

Grade Level:

HoursAboveBA:

HoursAboveMA:

PreviousEmploymentwithSchools--mostrecentfirst(listupto3)

NameofSchoolDistrict / Dates(to/from) / JobTitle

PreviousEmploymentnon-schoolrelated--mostrecentfirst(listupto3)

NameofBusiness / Dates(to/from) / JobTitle

RequiredQuestions:

Please answer Yes or No

1. Areyou able to performtheessential job functions which mayormaynot requirea reasonable accommodation?

2. Can you,afteremployment,submit verification of your legal right to workin theUnited

States?

3. Haveyou ever pled guilty or nolo contender to any offense,felony ormisdemeanor,otherthan a traffic violation that did not result in suspensionorrevocation of driver’slicense?

4. Do you now haveany pending criminal charges?

5. Have you ever been a party in an abuse and neglect proceeding?

6. Haveyou everresignedfromorotherwiseleft a public orprivateschool employmentto avoid investigation for alleged misconduct and/or dismissal in South Dakota orany other stateorplace?

7. Haveyou everbeendismissed ornot reemployedin any probationary orpermanent teaching position?

8. Areyou now a subject of any injury, disciplinaryaction, revieworinvestigation, in any district, by a teacherlicensing agency,orin thecourts of South Dakota orany otherstatein connection with any alleged misconduct?

9. Haveyou everhad any credential,application,permit,license,orotherdocument authorizing public school serviceorteaching suspended, revoked,voided, denied and/or otherwiserejectedfor causein South Dakota orin any otherstate?

10. Is any adverseaction now pending against any credential you hold which authorizes public school serviceorteaching in South Dakota orany otherstate?

Statelaw requiresthat all applicants prior to employmentbefingerprinted and prohibits employmentof any person convicted of certainsexoffenses,narcotic offenses,and violent crimes.

Answering"Yes"to any questions 3-10aboveis not an absolute bar to employment.

If you answered"Yes"to any questions 3-10above,please explain your answer(s).

Veteran’s Status

Do you wish to claim veteran’s preference? If yes, DD-214 (separation papers) must be

Attached. If you are a disabled veteran, attach current VA disability certification with DD-214

(separation papers)

State law requires residency in South Dakota to be eligible to receive veterans’ preference.

Are you currently a resident of the state of South Dakota?

Pleaselist3referencesotherthanrelativesandpreviousemployers

Name
Position
Company
Telephone