Please write legibly or type.
Date _____________________
Applicant’s Name _______________________________________________________________________________
Last Name First Name Initial
Present Address _________________________________________________________________________________
Street City State Zip
Telephone # ___________________________________________ Any Aliases __________________________
Social Security # ____________________________ Days Available (circle) M T W R F
Building/Grade Preferred (circle) Elementary School (K-6) Middle School (7-8) High School (7-12)
I. Education
I. Education Secondary School ____________________________________________ Graduation Date _____________
Address ____________________________________________
____________________________________________
Undergraduate _____________________________________________ Graduation Date ______________
Address _____________________________________________ # of credits __________________
_____________________________________________ Degree _____________________
Graduate _____________________________________________ Graduation Date ______________
Address _____________________________________________ # or credits __________________
_____________________________________________ Degree ______________________
Certifications Area_________________________________________ Date Issued ___________________
Area _________________________________________ Date Issued ___________________
State Issued ______________________________ (Please provide copies)
II. Experience
II. Experience Employer _________________________________________________ Started _____________________
Address __________________________________________________ Ended ______________________
__________________________________________________ Salary ______________________
III. Tenure Status Were you ever appointed to tenure in a public school district in New York State: Yes No
If yes, Tenure Area ________________________________________ Date tenure granted _____________________
Name and address of school district _________________________________________________________________
Were you ever dismissed from the school district conferring tenure pursuant to Education Law Section 3020-a?
Yes No
IV. Other information Are you willing to be examined by a school physician prior to employment Yes No
List persons working for us who know you ____________________________________________________________
Have you received fingerprint clearance documentation from the New York State Education Department?
Yes (See attached) No In Process
Have you been released or asked to resign from an employment position Yes No
If yes, please explain ________________________________________________________________________________
Ever been found guilty of professional misconduct in any state Yes No
Are you legally eligible for employment in this country Yes No
(Upon employment, you will be asked to produce two original forms of identification)
Please list your last three residences over the last ten years
___________________________________________________________________________________________________
Street City State Zip Time Period
___________________________________________________________________________________________________
Street City State Zip Time Period
___________________________________________________________________________________________________
Street City State Zip Time Period
V. References -Do not state, “See resume”.
V. References -Do not state, “See resume”.
Name _______________________________________________________ Occupation _______________________
Address _______________________________________________________ Telephone # _______________________
Name _______________________________________________________ Occupation _______________________
Address _______________________________________________________ Telephone # _____________________
Name _______________________________________________________ Occupation _______________________
Address _______________________________________________________ Telephone # _______________________
_______________________________________________________
Lyons Central School District is an Equal Opportunity Employer and is in compliance with Title IX, Regulations of the Education Amendment of 1972, which prohibits discrimination on the basis of sex.
Any false information provided will be grounds for disqualification/dismissal.
