Education and Professional Training (continue on separate sheet if necessary)

School / Name & Location / Dates Attended / Major / Diploma, Degree, or Certificate / Year Graduated
High School
Undergraduate College or University
Graduate or Professional
Other: Business, Military, etc.

Student Teaching Experience (List chronologically and include any internships, practicums, field experiences)

Name of School / School Division City/County / State / Grade Level and/or Subject / Dates

Teaching Experience (List chronologically all teaching experience, beginning with most recent. DO NOT INCLUDE SUBSTITUTE TEACHING

Name of School / School Division City/County / State / Grade Level and/or Subject Taught / Dates / Total Years / Reason for Leaving

Licensure

  1. If you have been issued a license, please submit a photocopy………………..Copy enclosed? [ ] Yes [ ] No Type of License: [ ] Provisional [ ] PG Professional [ ] Pupil Personnel [ ] Tech Year of Expiration of Virginia license______Endorsement(s)______Have you applied for a Virginia license? [ ] Yes [ ] No When?______Check if statement of eligibility is enclosed [ ]
  1. If you have been issued a license in another state, please submit a photocopy…Copy enclosed? [ ]Yes [ ] No

State______Expiration Date______Type of Endorsements______

State______Expiration Date______Type of Endorsements______

  1. Have you taken the Praxis Assessments for Teachers? (If yes, please submit a copy of your scors.)

Core battery: [ ] Yes [ ] No ______Copy enclosed? [ ] Yes [ ] No

Month Year Reading Writing Math Subject Area: [ ] Yes [ ] No ______Copy enclosed? [ ] Yes [ ] No

Month Year Subject Score

WORK EXPERIENCE OTHER THAN TEACHING: List in order starting with current employer

(Attach continuation sheet if necessary)

From: ______To: ______Position/Title:______[ ] Part Time [ ] Full Time

Employer: ______Telephone: ______

Complete Address: ______

Supervisor’s Name: ______May we contact? [ ] Yes [ ] No

Briefly describe your duties & responsibilities: ______

Reason for leaving: ______

From: ______To: ______Position/Title:______[ ] Part Time [ ] Full Time

Employer: ______Telephone: ______

Complete Address: ______

Supervisor’s Name: ______May we contact? [ ] Yes [ ] No

Briefly describe your duties & responsibilities: ______

Reason for leaving: ______

From: ______To: ______Position/Title:______[ ] Part Time [ ] Full Time

Employer: ______Telephone: ______

Complete Address: ______

Supervisor’s Name: ______May we contact? [ ] Yes [ ] No

Briefly describe your duties & responsibilities: ______

Reason for leaving: ______

Name / Title / Complete Address / Telephone Number

Extracurricular Activities: Indicate your number of years experience in the activities listed below. Circle activities that you are willing to coach/sponsor.

Extra Curricular Activities / High School Experience / College Experience / Contract Experience / Extra Curricular Activities / High School Experience / College Experience / Contract Experience
Baseball / Drama
Basketball / Forensics
Cheerleading / Honor Society
Cross Country / Intramurals
Football / Student Gov’t
Golf / Yearbook
Gymnastics / Other
Soccer / Other
Softball / Other
Tennis
Track
Volleyball
Wrestling
Weight lifting
debate

Writing Sample: In your own handwriting, provide any additional information that will provide an understanding of your qualifications, goals, objectives, educational philosophy, and other background factors of special interest.

______

______

______

I UNCONDITIONALLY CERTIFY that I have not been convicted of a felony or any offense involving the sexual molestation, physical or sexual abuse or rape of a child; and (ii) that I have not been convicted of a crime of moral turpitude. I further certify that I have not been the subject of a founded case of child abuse and neglect. I understand that making a materially false statement regarding any such offense is a Class 1 misdemeanor and upon conviction, the fact of said conviction shall be grounds of dismissal and for the Board of Education to revoke my license to teach. (Certification required by the Code of Virginia § 22.1-296.1.)

Applicant’s Signature______Date______

I UNCONDITIONALLY CERTIFY that I have carefully reviewed this completed application and have made true, correct, and complete answers and statements with respect to my application. I understand that any omission, misleading or incorrect statement or other representation made or implied by me, or any supplement thereto, whether written or oral, will be sufficient grounds for the failure to employ, or for immediate termination of employment by the School Board.

I ACKNOWLEDGE that I have a duty to immediately supplement this application to guarantee the accuracy of it at all times. I acknowledge that I will be required, as a condition of employment, to undergo a criminal history records review. I acknowledge that any employment offer/appointment made to me by the School Board will be conditioned upon the School Board’s receipt of background information. In the event the School Board determines, in its sole discretion, the existence of a material adverse report or omission as to any information, I agree that the employment offer/appointment will be deemed revoked immediately without further action or notice.

Applicant’s Signature______Date______

Attachments (check those that apply): [ ] Resume [ ] College Transcript [ ] Letter of Reference [ ] Other ______

*NOTE: Application of non-selectees are retained for a period of one year, after which they are destroyed.