Perry Central Community School Corporation

18677 Old State Road 37

Leopold, IN 47551

Teaching Position

Name______Date______

Street Address______Home Phone______

City, State, Zip______SSN______

For what position (grade or subject) do you wish to apply?______

Please give in detail your education and professional training.

School or Institution and Location / Degree/
Diploma / Years Attended / # Semester or Quarter Hours

Please give complete information regarding your teaching experience.

Name & Location of School / Grades/
Subjects / Dates / # Teachers in System

Underscore any of the following which you are able to direct or coach successfully: Debates, School Plays, Oratorical Contests, Orchestra, Band, Choirs, Clubs, Football, Basketball, Baseball, Softball, Track, Golf, Volleyball, Playground Activities, and any other ______

______

Last salary per year______

Do you hold an Indiana teaching certificate?______Give title and grades or subjects this license covers______

When could you begin work?______Are you under contract for next year?______

Please list at least 3 references:

Name/Position / Address / Phone

Professional organizations to which you belong:______

______

______

Please attach a copy of your transcript(s) if available now, or send as soon as possible.

In the space below, please briefly introduce yourself. Be sure to include your reasons for entering the teaching profession.

Please answer these additional questions and sign your name in the space provided:

  1. Are you presently being investigated or under a procedure to consider your discharge for misconduct by your present employer, or if you offered a resignation, your previous employer?

_____ Yes_____ No
If yes, please explain the circumstances on a separate sheet and attach it to this application.

  1. Have you ever been reprimanded, disciplined, discharged, or asked to resign from a prior position?

_____ Yes_____ No

If yes, please explain the circumstances on a separate sheet and attach it to this application.

  1. Have you ever resigned from a prior position without being asked, but under circumstances involving your employer’s investigation of sexual contact with another person, of mishandling of funds, or of criminal conduct?

_____ Yes_____ No

If yes, please explain the circumstances on a separate sheet and attach it to this application.

  1. Have you ever been charged with or investigated for sexual abuse of another person?

_____ Yes_____ No

  1. Have you ever been charged with, pleaded guilty or “no contest” (nolo contendere) to, or been convicted of any crime involving sexual abuse of any person or any other crime of moral turpitude? (Moral turpitude is an act of baseness, vileness, or depravity in the private and social duties which a person owes another member of society or society in general and which is contrary to the accepted rule of right and duty between persons, including, but not limited to, theft, attempted theft, murder, rape, swindling, and indecency with a minor.)

_____ Yes_____No

  1. Have you (a) ever been convicted of a crime, other than a minor traffic offense; or (b) ever entered a plea guilty or a plea of “no contest”, or has any court ever deferred further proceedings without entering a finding of guilty and placed you on probation, for any crime other than a minor traffic offense?

_____Yes_____No

If you have answered yes to any one of the previous three questions, please explain, in detail, including the date of the charge, the court action, the offense in question, and the address of the court involved: (attach additional pages if necessary)

______

Conviction of a crime is not an automatic bar to employment. The corporation will consider the nature of the offense, the date of the offense, and the relationship between the offense and the

position for which you are applying.

Any false or misleading information on this application shall be fully sufficient grounds to refuse to employ, or having been employed, shall be immediate cause for dismissal.

My signature below constitutes authorization to check my employment history, including without limitation, evaluations, criminal arrest and conviction record checks, reference checks, and release of investigatory information possessed by any private or public employer or any state, local, or federal agency. I further authorize those persons, agencies, or entities that the Perry Central Community School Corporation contacts in connection with my employment application to fully provide the Perry Central Community School Corporation any information on the matters set forth above. I expressly waive in connection with any request for or provision of such information, any claims, including without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the Perry Central Community School Corporation, its agents and officials or against any provider of such information.

______

(Signature)

Perry Central Community School Corporation

The Perry Central Community School Corporation is committed to equal opportunity. It is an Equal Opportunity Employer and does not discriminate on the basis of age, race, color, religion, sex, handicapping condition, or national origin, including Limited English Proficiency, in any employment opportunity. No person is excluded from participation in, denied the benefit of, or otherwise subject to unlawful discrimination on such basis under any education program or student activity.

If you have experienced discrimination in such educational programs or activities, written inquiries about procedures that are available and consideration of complaints alleging such discrimination should be directed to Tara Bishop, Assistant Superintendent, Perry Central Community School Corporation, 18677 Old State Road 37, Leopold, IN47551. Telephone (812) 843-5121.

For further information, clarification, or complaints, please contact the following persons:

Title IXMary Roberson, Superintendent of Schools

Perry Central Community School Corporation

18677 Old State Road 37

Leopold, IN 47551

(812) 843-5576

Section 504Pam Bell, Director

Exceptional Children’s Co-op

1502 St. Charles Street, Suite 2

Jasper, IN 47546

(812) 482-6661

A.D.A.Jeremy Edwards, Director of Building Maintenance

Perry Central Community School Corporation

18677 Old State Road 37

Leopold, IN 47551

(812) 843-5576