IV. Tenure Status
A. Were you ever appointed to tenure in a public school district in N.Y.S. Yes No
V. Other Information

Application of __________________________________________________________________________________________
Last Name First Name Middle Name

Present Address ________________________________________________________________________________________
Street City State Zip
Phone ( )______________________________________

Permanent Address ______________________________________________________________________________________
Street City State Zip
Phone ( )______________________________________

Teaching Position Sought ____________________________________________ Availability Date _____________________

I. Education
A. College or University Dates of Attendance Degrees or Credits
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________

B. Fields Major Hours Minor Hours
1. Undergraduate _________________________________________________________________________
2. Graduate _________________________________________________________________________

C. All Certificates Held and Subjects of Certification: ( please provide copies)

1. Permanent Provisional Initial Professional
___________________________________ ___________________ _____________________
Area Date Issued Expiration Date

2. Permanent Provisional Initial Professional
___________________________________ ___________________ _____________________
Area Date Issued Expiration Date

3. Permanent Provisional Initial Professional
___________________________________ ___________________ _____________________
Area Date Issued Expiration Date

If you do not have a NYS Teaching Certificate, have you applied for one? Yes No

If certified in another state, please describe. ___________________________________________________
Other licenses held: type and issuing authority __________________________________ Exp. Date _____
(please provide copies)

II. Experience (Student Teaching if no other teacher experience) (DO NOT STATE “See Resume”)
School ___________________________________ School _________________________________________
Address ___________________________________ Address ________________________________________
City, State, Zip _____________________________ City, State, Zip __________________________________
Position held _______________________________ Position held ____________________________________
Dates _____________________________________ Dates __________________________________________
Immediate Supervisor _______________________ Immediate Supervisor _____________________________
May we contact for references?________________ May we contact for references?______________________

School ___________________________________ School _________________________________________
Address ___________________________________ Address ________________________________________
City, State, Zip _____________________________ City, State, Zip __________________________________
Position held _______________________________ Position held ____________________________________
Dates _____________________________________ Dates __________________________________________
Immediate Supervisor _______________________ Immediate Supervisor _____________________________
May we contact for references? _______________ May we contact for reference?_______________________
III. Personal Data:
A. Social Security Number ________________________________________
B. N.Y.S. Retirement Number _____________________________________
C. From what secondary school did you graduate?
School ________________________________________________________________________
Address _______________________________________________________________________
City, State, Zip _______________________________________________ Year _____________
D. Present Salary ____________________________ Expected Salary ______________________
E. List persons working for us who know you. ___________________________________________
IV. Tenure Status

A. Were you ever appointed to tenure in a public school district in N.Y.S. Yes No
If yes, complete:
Tenure Area ____________________________________________________________________
Date Tenure Granted _____________________________________________________________
Name of school where tenure was granted __________________________________________
Address __________________________________________
City, State, Zip __________________________________________

B. Were you ever dismissed from the school district conferring tenure pursuant to Education Law section 3020-a? Yes No

V. Other Information
A. Have you ever been released or asked to resign from an employment position? Please explain: _______________________________________________________________________________
B. Have you ever been convicted of a crime in the past ten years, excluding minor traffic offenses? If yes, please explain on a separate sheet.

C.

Are you legally eligible for employment in this country? Yes No
(Upon employment you will be asked to produce two original forms of identification.)

VI. Extra Curricular: Underscore any of the following which you are able to direct or coach successfully: Debates, School Plays, Oratorical Contests, Orchestra, Clubs, Soccer, Football, Basketball, Baseball, Track, Tennis, Swimming, Lacrosse, Softball, Volleyball. Others:________________________________________________________________________________

VII. Candidate’s Statements (Complete Section VII in your own handwriting.) (Attach additional sheets if needed).

A. Why are you pursuing a career in education?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

B. What aspect of teaching gives you your greatest satisfaction? Why?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

C. If you had the choice, which students would you teach: a slow-learning group; an average group; a fast-learning group; a heterogeneous group? Why?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

D. What recent innovation in education seems to be most exciting and promising? Why?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E. Is there any other information you may desire to offer which will assist us to properly evaluate your promise as a teacher in the Lyons school?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VIII. References This area must be completed as requested. Do no state “See Resume.”

A. Name __________________________________________________________________________________
_______________________________________________________________________________________
Address City State Zip

Phone Number ( )_______________ Position _____________________________________________

B. Name __________________________________________________________________________________
_______________________________________________________________________________________
Address City State Zip

Phone Number ( )_______________ Position ___________________________________________

C. Name __________________________________________________________________________________
_______________________________________________________________________________________
Address City State Zip

IX. My placement folder may be obtained from ________________________________________________

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.

I authorize the Lyons Central School District to inquire, at their discretion, into my professional background and professional experiences and hereby release any member of agent of the district from any liability regarding me, whether or not said information is in my application. I further understand that the information, which is gathered, in part or whole, may be shared with members of the school district who are involved in the employment process. I further understand that all information gathered regarding my application will be the property of the school district and will not be released to me.

Signature ________________________________________________ Date _______________________________
Please return to: Superintendent of School
Lyons Central School District

10 Clyde Road
Lyons, New York 14489