GOUVERNEUR, NEW YORK 13642
Superintendent of Schools
Employment Application
Return to:
Mr. Thomas R. BurnsDistrict Superintendent
St. Lawrence-Lewis Counties BOCES
PO Box 231, 139 State Street Road
Canton, New York 13617
INQUIRIES:
Applicants are not to make direct contact with
Members of the Gouverneur Central School
Board of Education. All inquires are to be directed to: Mr. Thomas R. Burns,
(315)386-4504,Ext. 10150,
Application available at:
The Gouverneur Central School District is an equal opportunity employer and in compliance with Title IX of the educational Amendments of 1972, does not discriminate on the basis of race, color, religion, sex, age, or national origin.
APPLICATION
FILING
DEADLINE
AUGUST 1,
2011
1. Name
Last / First / Middle
2. Home Address
Street / City / State / Zip
3. Work Address
Street / City / State / Zip
4. Telephone – home address / Telephone – work address
5. New York State Certification:
Kind of
Certificate / No. of
Certificate / Date
Issued / Beginning
Date / Length of
Term / Certificate
Titles
6. Are you a member of the New York State Retirement System? If so, Membership No.
Date of membership / Rate of pension contribution / %
7. Social Security Number
8. Are you a United States Citizen?
9. Have you ever been convicted of a felony?
10. Have you ever been subject to a professional investigation by the Bureau of New York State Certification?
EDUCATION AND PROFESSIONAL TRAINING
Please fill in this section carefully and in detail.
Name of Institute and LocationIncluding High School, College, Graduate Work, and Summer Sessions in order taken. / Total Semester Hours Credit / Degree
or
Diploma Received / Major Subject
and Semester Hours Credit therein / Minor Subject
and Semester Hours Credit therein
List College honors received before or since graduation.
Were you trained for another profession or occupation before entering the field of education?
If so, what?
INTERNSHIP EXPERIENCE
List school, grade levels, and areas of responsibility.
School / Grade Level / Areas of Responsibility
EXPERIENCE IN TEACHING OR EDUCATIONAL ADMINISTRATION(Do not include student teaching)
Location / Name of School / Kind of Work
Grades or Subjects / No.
of
Yrs / Date
From-to / Salary per Year / Approx. No. of Teachers in System
Total Years
Number of students in present school district
Number of employees in present school district
Number of employees in your district reporting directly to you
Adult work experience other than education:
Name of Firmor Employer / City and State / Kind of Work / Date of Employment / Length of Service
Other experience with Children:
Type ofExperience / City and State / Kind of Work / Date of Employment / Length of Service
Have you ever been appointed on tenure in another district?
Where?
What is your present position? / Present Salary
Number of Years in Present Position
List dates of military services in Armed Forces of the United States
Have you ever received a dishonorable military discharge?
The 4th grade students at Gouverneur learned about Vincent Van-Gogh. They learnedthat he was an expressionist painter and then the students painted a replica of one of his most famous paintings - Starry Night.
These Japanese Kokeshi Dolls were made by third grade students from West Side and East Side Schools.
Kokeshi dolls originated in Japan and were created by Japanese woodworkers called Kijiya. They soldthese to tourists who visited their villages in the winter. However, only the wealthy would buy them and give them to their children. The Kokeshi dolls have common characteristics such a round head and a limbless body. The dolls are handpainted and no two faces are alike. That is perhaps the charm of these Kokeshi dolls.
References (3 or more):
A. Address of placement bureau of college with which you have registered for placement service:B. List superintendents, principals, supervisors, and Board of Education members under whom you have taught, and others who have first-hand knowledge of your character and ability as a teacher or administrator.
(NOTE: If recommendation from any of these persons are included in your placement bureau folder, please place an asterisk (*) before that name.)
Name / Address / Home
Phone / Office
Phone / Official Position
WAIVER AND RELEASE FOR APPLICANT BACKGROUND CHECK
By signing below, I______hereby authorize the District Superintendent of the Sole Supervisory District of St. Lawrence-Lewis Counties, acting on behalf of the Gouverneur Central School, to verify and investigate all statements I have made on the employment application, related papers, and in interviews. I authorize the District Superintendent to contact all employers and personal references listed on my employment application. In addition, I authorize all individuals, schools and employers mentioned on my employment application to freely provide any information requested that may be relevant and helpful in making a hiring decision. I release any such individuals, schools, and employers from any and all legal liability or damage for disclosing any information about me. In addition, I understand that if this form is not signed and submitted with the appropriate completed application form, I will not be considered for employment by the District.
Signature______Date______
APPLICANT’S STATEMENTI certify that all statements herein are true, accurate, and complete, and I understand that any false, misleading or willful omissions shall be just cause for dismissal or refusal of employment.
I understand that the District Superintendent, acting on behalf of the Gouverneur Central School District, will thoroughly investigate my work and personal history and verify all data given on this application, related papers, and in interviews.
I authorize all individuals, schools, and employers mentioned therein to provide any information requested about me, and I release them from any and all legal liability or damage for disclosing information about me.
I understand that I am not guaranteed employment by merely completing this application and even if I am hired by the District, this document is not to be considered a contract for employment.
Pursuant to the School Finger Printing Law (2000 New York Laws, Chapter 180), I understand that I will not be eligible for employment by the District if the New York State Education Department does not clear me for employment after my fingerprints are reviewed by the Division of Criminal Justice Services.
If requested by the District in connection with this application and if given a bona fide offer of employment, I agree to take a medical examination in accordance with District policies. I agree that the examining authority may disclose the findings of these examinations to the District and that my initial employment is conditional upon meeting the requirements of that examination as established by the District.
Signature______Date______