Application Date

Last Name

First Name

Middle Name

Social Security Number

Address Street & Number

City

State

Zip

Home Telephone

Work Telephone

Permanent Address (if different)

Street & Number

City

State

Zip

Telephone Number

What type of Kansas Teaching Certificate will you hold next September 1?

Certificate Codes

Expiration Date

Valid in Elementary

Valid in Secondary

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Other areas of Certification

Please indicate position desired: Subject or Field (in order of preference)

Senior High School

Junior High School

Middle School

Elementary (Grade Choice)

1st Choice

2nd Choice

3rd Choice

Special emphasis in any areas such as art, music, foreign language, science, remedial reading, etc.

Graduate of:

High School

Address

Date

Professional Preparation: (include summer school and extension work).

College or University

City and State

Year(s) Attended

Year Grad.

Degree

Hours

Teaching Major

Teaching Minor

Which college placement bureau has your credentials on file?

PLEASE REQUEST THAT YOUR COLLEGE SEND US A COPY OF YOUR CREDENTIALS

 

Teaching Experience

Date

Name of School

City

State

Grade or Subject
From

To

No. of School Terms

Other Work Experience

Employer

City or State

Nature of Work

Date

References: Teaching Experience

(Should include the superintendent; principal, and/or your supervisor of Student Teaching)

Name

Address

Vocation

Do you have any personal convictions that would prevent you from participating in any phase of public education or working in any sponsored activity?

Yes No

If yes, please explain

Present Position

Location

Present Annual Salary

Expected Annual Salary

Reason for leaving present or last position.

In what professional organizations do you hold membership?

List college activities engaged in, honors received during or since graduation, and other significant experiences you have had that would be helpful to you as a teacher

This remaining space may be used for additional information which you feel is pertinent to this application and information you believe will assist in arriving at a true estimate of your qualifications.

 
An Equal Employment/Educational Opportunity Agency

Smoky Valley Public Schools No. 400 does not discriminate on the basis of sex, race, color, national origin, disability, or age, in admission to access to, or treatment or employment in, its programs or activities. Any questions regarding the Board's compliance with Title VI, Title IX, Section 504 or the Americans with Disabilities Act may be directed to the district compliance offficer, Mr. Glen J. Suppes, who can be reached at 126 S. Main, Lindsborg, Kansas, or the Office for Civil Rights of the Department of Education, (816) 891-8026. The Compliance Officer can also be contacted for the existence and location of accessible services, activities, and facilities.

 



      

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