APPLICATION FOR EMPLOYMENT. Position Applying For: Date: Personal Information. Name Last First Middle Mailing Address Street

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1 Winnisquam Regional School District SAU 59 Communities United For Excellence in Education 433 West Main, Tilton, New Hampshire Telephone (603) Fax (603) Web Site: APPLICATION FOR EMPLOYMENT Position Applying For: Date: Personal Information Name Last First Middle Mailing Address Telephone # Home Work Cell Social Security Number: Address: Do you have the legal right to accept employment in the US? Yes No Employment History Please list current and at least two former employers, starting with the most recent. All employers will be contacted to verify employment history information, unless you indicate you do not want us to contact them and the reason why. This request will be honored in the initial phase of the application. If you become a final candidate for the job, we will be utilizing the Release of Information in making contact. Employer: Phone: Employer: Phone: 1

2 Employer: Phone: Employer: Phone: Education High School Attended: Trade/Tech. College: Undergraduate College: Graduate College: Additional Information (You may add information such as committee, volunteer, civic, co-curricular, coaching, or other life experiences not included earlier) Certification Information NH Teaching Certificate: Yes No Certificate No: Expiration Date: Areas of Endorsement: Have you taken the Pre-Professional Skills Test (PRAXIS)? Yes No If currently in process of being certified, which alternative plan are you using? (If you are in process of completion of a teacher certification program, you must provide a letter stating that you have successfully completed the program.) 2

3 References Name Occupation Telephone No Other Information 1. Candidates should enclose transcript(s) or have them forwarded to this office by your placement office. If you are hired, you will need to provide certified transcripts to the District. 2. Interviews will be scheduled with selected candidates on the basis of education, experience, other qualifications, and available openings. 3. An offer of employment is contingent upon the results of a physical exam and TB test. Information obtained in a post-offer exam will be treated as a confidential medical record and used in accordance with the American Disabilities Act (ADA). 4. The District s evaluation of the qualifications of an employee or candidate and hiring decisions are made without regard to factors such as sex, race, color, national origin, creed, lawful political or organization affiliation, age, marital status, sexual orientation, or physical or mental disability. 5. Please check yes or no to the following four questions: a. Teacher license: Revoked or Suspended? _ yes no b. Has your position with a School District ever been non-renewed? yes no c. Have you been dismissed, terminated, or forced to resign by an employer within the last 10 years? yes no d. Have you ever been employed by the Winnisquam Regional School District? yes no Please attach any additional information or explanation on a separate piece of paper. To your knowledge, do you have any relatives working in the Winnisquam Regional School District? If so, who and in what capacity? (Policy GBEBE) Notice: Your answers to the following questions will not necessarily bar you from employment with the Winnisquam Regional School District. When the District is considering whether an offer of employment will be made, factors such as age and time of offense, seriousness and nature of violation, and rehabilitation are taken into account in determining your current fitness for employment with the District. 1. Have you been convicted and/or been found guilty by a court of competent jurisdiction or a state agency serving in a judicial capacity of: (a) a criminal offense yes no or (b) any offense involving sexual misconduct, moral turpitude, or abuse of children? yes no. If so, please describe the offense, the date and place of conviction, underlying circumstances, and any other information which will help us evaluate your current fitness for employment. State of Conviction: Misdemeanor: Felony: 3

4 Employment Application Certification and Authorization for Release of Information I certify that all the statements made in this application are true and complete to the best of my knowledge. I understand that a false or incomplete answer may be grounds for not hiring me or for dismissing me after I have begun work. I understand that all of the information contained in this application may be subject to verification and investigation by the Winnisquam Regional School District. I hereby authorize any representative of the Superintendent s office of the Winnisquam Regional School District bearing this release to verify and to investigate all facts contained in my application for employment with the School District as may be necessary in arriving at an employment decision. I hereby authorize the Superintendent s office to obtain all information concerning my employment with present or past employers, as well as additional information including but not limited to my education, disciplinary history, attendance record, or any other records, wherever located, which may pertain to my professional background. I further authorize all of my present and previous employers to provide any and all information and documentation concerning my employment and any other pertinent information which said employers may have, including performance records, but excluding medical or genetic information or records upon the request of the bearer of this release. This release is executed with the full knowledge and understanding that the information is for the official use of the Winnisquam Regional School District. I hereby release all parties, including past and present employees as well as the Winnisquam Regional School District, including its officers, directors, agents, employees, and related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. I understand that unless altered by contract or statute, nothing in this application, certification, or release creates an employment contract. I also understand that any offer of employment extended to me by the Winnisquam Regional School District is conditional upon verification of: (1) the physical examination and TB Test results; and (2) a satisfactory background investigation in accordance with the Department of Education and RSA 189:13-a. I hereby voluntarily, without duress, coercion, or threats, agree to an intensive background search conducted by members of the Winnisquam Regional School District and the State of New Hampshire State Police, Federal Bureau of Investigation, and the local Police Department(s) or its designee in accordance with RSA 189:13-a. By signing this application, I certify that I have never been convicted of a criminal offense other than those I have specifically listed in this application. I further certify that I have never been convicted of any offense involving sexual misconduct, moral turpitude, or abuse of children. Signature of Applicant: Date: Please send completed application, transcripts and references to: Winnisquam Regional School District 433 West Main, Tilton, NH Updated 2/2016 4

5 Name: Position Applying For: Please respond to the following questions in the space provided. 1. Describe a single professional achievement of which you are most proud. 2. Explain how you would address the learning needs of all students. 3. What research-based practices show the most improvement in student achievement?

6 4. How would you describe your teaching style? 5. Summarize the reason(s) you are applying for this particular position. Teacher Addendum