KESHEQUA CENTRAL SCHOOL DISTRICT
15 Mill Street, P.O. Box 517
Nunda, New York 14517
Ph: 5854682541 Fax: 5854683814
PROFESSIONAL STAFF APPLICATION
POSITION PREFERENCE
Elementary
Middle School
High School
Other
(Guidance,
FullTime
PartTime
Psychology,
Administrator)
Please specify preferences: Grade Level
Subject Areas
PERSONAL INFORMATION
Name
Last
First
M.I.
Other Name(s)
Please provide any additional information regarding names you have used, which may be
necessary to enable a check of your work or school records.
Present Mailing Address
Phone
Permanent Mailing Address
Phone
Social Security #
N.Y.S. Teachers’ Retirement#
NEW YORK STATE CERTIFICATION
N.Y.S. Certification:
Yes
No
Pending
If yes or pending please complete:
Area
Subject
Initial
Professional Transitional
Provisional
Permanent
Effective Date
Expiration Date
Certificate #
Area
Subject
Initial
Professional Transitional
Provisional
Permanent
Effective Date
Expiration Date
Certificate #
New York State Coaching Certificate
Yes
No
Pending
The Keshequa Central School District does not discriminate because of race, color, creed,
religion, national origin, political affiliation, sex, sexual orientation, age, marital
status, military status, veteran status, or disability.
Please attach a copy of all certificates
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EDUCATION AND PROFESSIONAL TRAINING
School Attended
Location
Dates
Degree
Major
Minors
High School
Undergraduate
Graduate
Total Number of
Graduate Hours
beyond last degree
TEACHING EXPERIENCE
List most recent experience first. Include any substitute teaching and indicate as such.
Administrative applicants: please include both administrative and teaching experience.
Inclusive Dates:
Name and Location of
School
Specific Nature of
Position: i.e., grade
level, subject, etc.
Total
Years
If full
time
position,
annual
salary
Did you
receive
tenure?
From
To
1.
2.
3.
4.
Reason for Leaving (Refer to numbers above)
Reason for Leaving (Refer to numbers above)
1.
2.
3.
4.
EDUCATIONAL EXPERIENCE
If fewer than 3 years of regular fulltime employment, include student teaching experience here.
Inclusive Dates:
From
To
Name and Location of School
Subject or Grade Level
1.
2.
RELATED PROFESSIONAL EXPERIENCE
Educational travel, lectures, addresses, publications, organizational memberships, committee chairs
or memberships, participation in educational experiences, innovations, special programs, elective
positions held. This section should include your experience with computers and technology as
organizational tools (i.e., word processing, spreadsheets, database) to instructional delivery
(i.e., Internet, CD Rom multimedia, distance learning).
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MILITARY SERVICE AND WORK EXPERIENCE OTHER THAN TEACHING
List here in chronological order all practical experience other than teaching, including trade or
business experience, military service, social work, work in summer camps, involvement with youth
activities, etc.
Inclusive Dates
Kind of Work
From
To
Name and Address of Employer
Name and Address of Supervisor who
would know most about this work.
List below any extracurricular or athletic activities you can direct.
Estimate your attendance at work or school for the last three years (days, weeks, months)
Excellent
Very Good
Good
Fair
Poor
Have you ever been dismissed or asked to resign? Have you ever agreed to resign or agreed
to accept a disciplinary penalty in settlement of disciplinary charges? Have you ever
resigned to avoid a denial of tenure or dismissal during a probationary period? If yes to
any or all of the above, please explain:
Are you a party to any agreement with a prior employer limiting the right of your prior
employer to respond to reference checks by prospective employers? If yes, please explain
Except for minor traffic violations, have you ever been convicted of a crime?
If yes, please give details
REFERENCES
Give names of those who have closely observed your work as a teacher or as a student. In
the case of experienced teachers or supervisors, present and former superintendents,
principals and other supervisors are preferred. Beginning teachers will please include
practice teaching supervisors. If references may not be contacted before a certain date,
please indicate the date by the name of the reference.
Office Use
Name
Official
Position
Present Address/Zip/Phone
Sent
Rec’d
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In your own handwriting state why you feel you are well qualified for employment with the
Keshequa Central School District and any additional professional information that you
think might be of value in our considering you for a position.
Thank you for completing this application and for
your interest in Keshequa Central School.
Please return application to:
Superintendent
Keshequa Central School
P.O. Box 517
Nunda, New York 14517
I hereby certify that the statements made in this application are true to the best of my
knowledge and belief. I hereby authorize any individual, company, or institution with
whom I have been associated to furnish the Keshequa Central School District with any
information concerning my employment.
Date
Signature of Applicant
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